THE  LIBRARY 

OF 

THE  UNIVERSITY 
OF  CALIFORNIA 

LOS  ANGELES 


GIFT  OF 


State   Medics  1  Society 


AN 

INTERNATIONAL  CONGRESS 
OF  OPHTHALMOLOGY 


WASHINGTON,  D.  C. 

APRIL  25,  26,  27,  28,  1922 


Held  Under  the  cAuspices  of 


THE  AMERICAN  OPHTHALMOLOGICAL  SOCIETY  •  THE 

SECTION   ON   OPHTHALMOLOGY   OF   THE  AMERICAN 

MEDICAL  ASSOCIATION  •  THE  AMERICAN  ACADEMY  OF 

OPHTHALMOLOGY  AND  OTO-LARYNGOLOGY 

WASHINGTON,  D.  C. 
1922 


EDITED  BY  THE 
COMMITTEE  ON  PUBLICATION 
DR.  WILLIAM  2ENTMAYER,  CHAIRMAN 

DR.    WILLIAM    M.   SWEET 
DR.   ARNOLD    KNAPP 
DR.    LUTHER   C.   PETER 


WM.  F.  FELL  CO.  PRINTERS 
PHILADELPHIA 


Library 

W3 


CONTENTS 

PAGE 

Officers  of  the  Congress 5 

Official  Government  Representatives 6 

Members  of  the  Congress 7 

Address  of  Welcome 31 

Presentation  of  Credentials 32 

Report  of  Committee  on  Nominations 36 

Salutatory  of  President  of  Congress ' 37 

Des    Enseignements    de    la    Guerre    en   Chirurgie  Oculaire.     Prof.  F.   de 

Lapersonne,  Paris,  France 39 

Detachment  of  the  Vitreous.     Sir  William  Lister,  London,  England 50 

On  Diaphragm  Lamps  in  Ophthalmology.    Prof.  Allvar  Gullstrand,  Sweden     69 
Sintomas  Oculares  del  Envenenamiento  por  el  Piquete  de  Alacran.    Dr.  Jose 

de  Jesus  Gonzalez,  De  Leon,  Gto.,  Mexico 81 

Traitement  du  Trachome  par  les  Injections  sous  Conjonctivales  de  Cyanure 

de  Mercure.     Dr.  Gemblath,  Paris,  France 95 

Hereditary  Ocular  Degenerations.    "Ophthalmic  Abiotrophies. "   E.  Treacher 

Collins,  London,  England 103 

Bitemporal  Contraction  of  Visual  Fields  in  Pregnancy.    Prof.  C.  E.  Finlay, 

Havana,  Cuba 144 

Les  Echanges  d'Eau  et  d'lons  a  Travers  la  Cornee.    Dr.  V.  Morax,  Paris, 

France 157 

Psyche-pathology  in  Ophthalmic  Practice.    Dr.  Charles  F.  Harford,   Cam- 
bridge, England 160 

Nuevo  Tratamiento  Quirurgico  del  Estrabismo.    Dr.  B.  Castresana,  Madrid, 

Espana 171 

A  New  Procedure  in  the  Excision  Method  of  Pterygium  Operation.    Dr.  E. 

Campodonico,  Lima,  Peru 201 

The  Subconjunctival  Excision  of  Pterygium.     Dr.  S.  Lewis  Ziegler,  Phila- 
delphia     205 

La  Tuberculosis  Ocular  Infantil.    Dr.  Francisco  Poyales,  Madrid,  Espana. .   214 
Endophthalmitis   Phacoanaphylactica.      Drs.    F.    H.    Verhoeff  and  A.    N. 

Lemoine,  Boston,  Mass 234 

Serum  and  Vaccine  Treatment  for  the  Prevention  and  Cure  of  Cataract.    Dr. 

A.  Edward  Davis,  New  York  City 284 

Facoerisis.     Prof.  Ignacio  Barraquer,  Barcelona,  Espana 313 

Operation  de  Barraquer.    Prof.  Gallemaerts,  Bruxelles 319 

Troubles  Oculaires  Consecutifs  a  1'Observation  Directe  de  1'Eclipse  Solaire. 

Dr.  Dragoutine  Kostitch,  Belgrade,  Jugo-Slavia 340 

Orbital  Marsupialization  and  Superiority  of  Organic  Grafts  of  Dead  Tissue  in 

Establishing  a  Mobile  Stump.    Dr.  A.  Magitot,  Paris,  France 359 

La  Peritomia  en  las  Ulceras  Cr6nicas  Vasculares  de  la  Cornea.    Dr.  Antonio 

F.  Alonso,  Mexico,  D.  F 371 

Types  of  Pneumococcus  Found  in  Corneal  Ulcers.     Dr.  Robert  Cartwright 

Cheney,  Boston,  Mass 378 

L'Etat  Vasculaire  des  Glaucomateux  (Etude  de  100  Malades  de  Glaucome 

Primitif).    Dr.  Carlos  Charlin,  Santiago,  Chile 383 

3 


PAGE 

The  Diagnosis  of  Glaucoma.    Lt.-Col.  R.  H.  Elliot,  London,  England 405 

Blood-Pressure  in  the  Vessels  of  the  Eye.  Dr.  A.  Magitot  and  Dr.  P.  Bailliart, 

Paris,  France 435 

Plastic  Operations  about  the  Eye.    Dr.  John  M.  Wheeler,  New  York  City. .  443 

Lagophtalmie  Bilaterale  Consecutive  a  la  Perte  Accidentelle  de  la  Peau  du 
Front,  et  du  Cuir  Chevelu.  B16pharoplastie.  Dr.  J.  N.  Roy,  Montreal. 
Canada 460 

Light-Sense:  The  Practical  Significance  of  its  Variations:  Simple  Tests  for 
Determining  Them.  Archibald  Stanley  Percival,  M.A.,  M.B.,  B.C., 
Camb.,  Newcastle-upon-Tyne,  England 468 

Some  Contributions  to  the  Science  and  Practice  of  Ophthalmology.  C.  E. 

Ferree,  Ph.D.,  and  G.  Rand,  Ph.D.,  Bryn  Mawr,  Pa 479 

Le  Diagnostic  et  la  Mesure  des  Vices  de  Refraction  au  Moyen  de  la  Fente 

Ste"nopeique  et  du  Cadran  Horaire.  Dr.  Emile  Junes,  de  Sfax,  Tunisie  .  520 

Anomalies  of  Ocular  Development  and  Pigmentation.  J.  Gray  Clegg,  M.D., 

B.S.,  F.R.C.S.,  Manchester,  England 528 

Los  Mercuriales,  el  Salvarsan  y  sus  Derivados  en  el  Tratamiento  de  las  Formas 
Graves  de  Conjuntivitis  y  Queratitis  Eczematosas.  Dr.  Antonio  Torres 
Estrada,  Mexico,  D.  F 533 

The  Effects  of  Direct  Instillation  of  Novarsenobillon  in  the  Conjunctival  Sac 
in  Resistant  Cases  of  Congenital  Syphilitic  Interstitial  Keratitis.  Dr. 
Arnold  Renshaw,  Manchester,  England 548 

Tratamientos  de  las  Queratitis  Infecciosas  por  las  Vacunas.  Dr.  Rovirosa 

Virgili,  Madrid,  Espana 551 

Carcinoma  of  the  Choroid.     Dr.  Allen  Greenwood,  Boston,  Mass 567 

Metastatic  Thyroid  Tumor  in  the  Orbit.     Dr.  Arnold  Knapp,  New  York  City.   573 

Bilateral  Lymphosarcoma  of  the  Orbit  with  Intermittent  Exophthalmos. 
Drs.  Walter  Scott  Franklin  and  Frederick  C.  Cordes,  San  Francisco,  Cali- 
fornia    579 

Chloroma.     Dr.  Arthur  J.  Bedell,  Albany,  N.  Y 588 

PROPOSITIONS  FOR  CONGRESS  ACTION 

The  Value  of  Letters  and  Characters  as  Visual  Tests.     Dr.  A.  E.  Ewing,  St. 

Louis,  Mo 604 

Ophthalmologic  Versus  Anatomic  Nomenclature.  Dr.  M.  Uribe  Troncoso, 

New  York  City 607 

Standardization  of  Perimetric  Technic.  Dr.  Luther  C.  Peter,  Philadelphia.  . .  615 

ADDRESSES  DELIVERED  BEFORE  THE  CONGRESS 

Some  Descriptive  Errors  in  the  Anatomy  of  the  Orbit.    Prof.  S.  E.  Whitnall, 

Montreal,  Canada 617 

On  the  Clinical  Anatomy  of  the  Efferent  Lacrimal  Passageways.  J.  Parsons 

Schaeffer,  Philadelphia,  Pa 625 

The  Facts  and  Theories  of  Color  Vision.  Prof.  Leonard  Thompson  Troland, 

Cambridge,  Mass 652 

The  Production  and  Transmission  of  Certain  Eye  Defects.  Prof.  M.  F. 

Guyer,  University  of  Wisconsin 669 

A  New  Technic  for  the  Application  of  the  Method  of  Cajal  to  Sections  of  the 

Retina.  Dr.  Felix  Fernandez  Balbuena,  Gijon,  Spain 690 

Minutes  of  the  Proceedings 692 

Organization  of  the  Congress 705 

International  Congress  Committees 706 

4 


AN   INTERNATIONAL  CONGRESS  OF 
OPHTHALMOLOGY 

OFFICERS  OF  THE  CONGRESS 

PRESIDENT 
DR.  G.  E.  DE  SCHWEINITZ,  OF  PHILADELPHIA,  PA. 

VICE-PRESIDENTS 

DR.  FRANCISCO  J.  SORIANO,  OF  ARGENTINE 

PROF.  EMILE  GALLEMAERTS,  OF  BELGIUM 

DR.  CESARIO  DE  ANDRADE,  OF  BRAZIL 

DR.  PIMENTAL  FRANCO,  OF  BRAZIL 

DR.  T.  M.  Li,  OF  CHINA 

PROF.  C.  E.   FINLAY,  OF  CUBA 

DR.  WILLIAM  Z.  HONS,  OF  CZECHO-SLOVAKIA 

E.TREACHER  COLLINS,  F.R.C.S.,  OF  ENGLAND 

PROF.  F.  DE  LAPERSONNE,  OF  FRANCE 

PROF.  G.  F.  ROCHAT,  OF  HOLLAND 

DR.  SALVATORE  FLORIA,  OF  ITALY 

DR.  AURELIO  BERAUN,  OF  PERU 

DR.  GEORGE  MACKAY,  OF  SCOTLAND 

PROF.  IGNACIO  BARRAQUER,  OF  SPAIN 

DR.  D.  FRANCISCO  POYALES,  OF  SPAIN 

PROF.  ALLVAR  GULLSTRAND,  OF  SWEDEN 

DR.  LUCIEN  HOWE,  OF  UNITED  STATES 

DR.  EDWARD  JACKSON,  OF  UNITED  STATES 

DR.  SANTOS  DOMINICI,  OF  VENEZUELA 

SECRETARY -TREASURER 
DR.  LUTHER  C.  PETER,  OF  PHILADELPHIA,  PA. 

SECRETARIES 

DR.  ALBERT  LASALLE,   MONTREAL,  CANADA FRENCH 

DR.  FRANCISCO  M.  FERNANDEZ,  HAVANA,  CUBA  —  SPANISH 
DR.  JESUS  M.  PENICHET,  HAVANA,  CUBA FRENCH  AND  SPANISH 


OFFICIAL   GOVERNMENT   REPRESENTATIVES 
CHINA 

DR.  T.  M.  LI 

PEKING  UNION  MEDICAL  COLLEGE 

CUBA 

PROF.  C.  E.  FINLAY 

DR.  J.  M.  PENICHET 

DR.  F.   M.   FERNANDEZ 

HAVANA 

GREAT  BRITAIN 

MR.    EDWARD    TREACHER   COLLINS,    F.R.C.S. 

DR.  GEORGE  MACKAY 

VICE-PRESIDENT.  OF  EDINBURGH.  SCOTLAND.  TO  REPRESENT  THE  ROYAL 
COLLEGE  OF  SURGEONS  OF  EDINBURGH 

ITALY 

DR.    SALVATORE    FLORIA 

NETHERLANDS 

PROFESSOR  G.  F.  ROCHAT 

PROFESSOR  OF  OPHTHALMOLOGY.  UNIVERSITY  OF  GRONINGEN,  PRESIDENT 
OF  THE  OPHTHALMOLOGICAL  SOCIETY  OF  THE  NETHERLANDS 

PERU 

DR.  AURELIO  BERAUN 

SPAIN 

DR.  IGNACIO  BARRAQUER 
PROFESSOR  OF  OPHTHALMOLOGY.  UNIVERSITY  OF  BARCELONA 

DR.  D.  FRANCISCO  POYALES 
CENTRAL  UNIVERSITY,  MADRID 

SWEDEN 

PROFESSOR  ALLVAR  GULLSTRAND.  PH.D. 
UPSALA 

UNITED  STATES 

ARMY  MEDICAL  CORPS 
LIEUTENANT-COLONEL  F.    H.   GARRISON 

NAVY  MEDICAL  CORPS 
LIEUTENANT  JAMES  F.  HOOKER 

PUBLIC  HEALTH  SERVICE 
SURGEON  JOHN  MCMULLEN 


REPRESENTATIVES    FROM    SOCIETIES   AND 
UNIVERSITIES 

ACADEMIE  DE  MEDECINE  DE  PARIS 
FACULTE  DE  MEDECINE  DE  PARIS 

PROFESSOR  F.  DE  LAPERSONNE 
ASOCIACION  MEDICA  ARGENTINA 

DR.  FRANCISCO  J.  SORIANO 

FACULDADE  DE  MEDICINA  DA  BAHIA.   BRAZIL 

SOCIEDADE    MEDICA    DOS    HOSPITAN  DA  BAHIA.  BRAZIL 

DR.  CESARIO  DE  ANDRADE 

DR.  PIMENTAL  FRANCO 
PEKING  UNION  MEDICAL  COLLEGE,  CHINA 

DR.  T.  M.  LI 

UNIVERSITE  DE  BRUXELLES 

SOCIETE  BELGE  D'OPHTALMOLOG  IE 

PROFESSOR  EMILE  GALLEMAERTS 


MEMBERS  OF  AX  INTERNATIONAL 
CONGRESS  OF  OPHTHALMOLOGY 

Members  present  are  indicated  by  * 

FOREIGN  MEMBERS 

ARGENTINE  REPUBLIC 

Manes,  Dr.  Antonio  J.,  Buenos  Aires 

Noceti,  Dr.  Adolfo,  Buenos  Aires 

Oneto,  Dr.  Jose  A.,  Buenos  Aires 

Soriano,  Dr.  Francisco  J.,  Buenos  Aires 


AUSTRALIA 
*Spring,  Dr.  J.  F., 

BELGIUM 
*Gallemaerts,  Professor  Emile, 


BRAZIL 


de  Andrade,  Dr.  Cesario, 
Buriner,  Dr.  Jose  P., 
Franco,  Dr.  Pimental, 
Gomes,  Dr.  Pereira, 


*Arrell,  Dr.  W., 
Badeaux,  Dr.  Georges, 
Bousquet,  Dr.  Paul  E., 

*Byers,  Dr.  W.  M.  Gordon, 

"Campbell,  Dr.  Colin  A., 
Chipman,  Dr.  L.  D.  V., 

*Courtney,  Dr.  J.  D., 
Cunningham,  Dr.  Allan  R., 
Doull,  Dr.  Arthur  E., 

*Fales,  Dr.  A.  C., 

*Fraser,  Dr.  W.  G., 

*Kerry,  Dr.  Richard, 

*Lassalle,  Dr.  Albert, 
Laurent,  Dr.  E.  E., 

*Lyon,  Dr.  Mortimer, 
MacCallum,  Dr.  James  M., 

*McCulloch,  Dr.  R.  J., 

*MacMillan,  Dr.  John  A., 

*MacNeil,  Dr.  F.  A., 
Mathers,  Dr.  R.  Evatt, 
Mathewson,  Dr.  Geo.  H., 

*McAuley,  Dr.  A.  G., 

*MacDonald,  Dr.  Wm.  A., 


CANADA 


Melbourne 
Brussels 


Bahia 
Campinas 
Sergipe 
S.  Paulo 


Ontario 

Montreal 

Montreal 

Montreal 

Toronto 

New  Brunswick 

Ottawa 

Halifax,  N.  S. 

Halifax,  N.  S. 

Middleton,  N.  S. 

Ottawa 

Montreal 

Montreal 

Montreal 

Toronto 

Toronto 

Toronto 

Montreal 

Winnipeg,  Manitoba 

Halifax,  N.  S. 

Montreal 

Montreal 

Windsor 


8  Members  of  An  International  Congress  of  Ophthalmology 

McKenty,  Dr.  Francis  D.,  Winnipeg,  Manitoba 

*Minnes,  Dr.  Robt.  S.,  Ontario 

Morton,  Dr.  Jos.  P.,  Ontario 

Panneton,  Dr.  Auguste,  Quebec 

*Putnam,  Dr.  W.  G.,  Nova  Scotia 

*Rosenbaum,  Dr.  Jacob,  Montreal 

*Roy,  Dr.  J.  N.,  Montreal 

Sebert,  Dr.  Louis  J.,  Toronto 

Smith,  Dr.  I.  R.,  Toronto 

*Smith,  Dr.  W.  Harvey,  Winnipeg,  Manitoba 

*Stirling,  Dr.  J.  W.,  Montreal 

Thompson,  Dr.  Septimus,  Ontario 

*Tooke,  Dr.  Fred.  T.,  Montreal 

Trites,  Dr.  C.  Bruce,  Nova  Scotia 

*Whitnall,  Professor  S.  Ernest,  Montreal 

*Wright,  Dr.  Walter  W.,  Toronto 


CENTRAL  AMERICA 

Guillen,  Dr.  Joaquin,  El  Salvador 

Luna,  Dr.  R.  Pacheco,  Guatemala 

CHILE 

Barranechea,  Dr.  M.  J.,  Santiago 

Charlin,  Dr.  Carlos,  Santiago 

CHINA 

*Li,  Dr.  T.  M.,  Peking 

COSTA  RICA 

Herdocia,  Dr.  Constantino,  San  Jose 

CUBA 

Altuna,  Dr.  Manuel,  Cienfuegoa 

*Fernandez,  Dr.  Francisco  M.,  Havana 

Fernandez,  Dr.  Juan  Santos,  Havana 

*Finlay,  Prof.  Carlos  E.,  Havana 

Guiral,  Dr.  Rodolfo,  Havana 

*Gutierrez,  Dr.  Gerardo,  Havana 

*Penichet,  Dr.  Jesus  M.,  Havana 

CZECHOSLOVAKIA 
*Hons,  Dr.  William  Z. 

DOMINICAN  REPUBLIC 

Grullon,  Dr.  A.,  Santiago 

ECUADOR 

Rubio,  Dr.  Juan  F.,  Guayaquil 

EGYPT 

MacCallan,  Dr.  A.  F.,  Cairo 


Members  of  An  International  Congress  of  Ophthalmology          9 


ENGLAND 

*Clegg,  Mr.  John  Gray, 
"Collins,  Mr.  Edward  Treacher, 
*Elliot,  Lt.-Col.  R.  H., 
Lauford,  Mr.  John  B., 
Paton,  Mr.  Leslie, 
Percival,  Mr.  Archibald  S., 


Manchester 

London 

London 

London 

London 

Newcastle-on-Tyne 


FRANCE 


Chaillous,  Dr.  J., 
*Gemblath,  Dr.  Said, 

Jeandelize,  Prof.  Paul  C., 

Junes,  Dr.  Emile, 

Koenig,  Dr.  Chas.  I., 
*de  Lapersonne,  Prof.  F., 
*Magitot,  Dr.  A., 

Morax,  Dr.  Victor, 


Morgan,  Dr.  James  A., 


HAWAII 


Paris 

Paris 

Nancy 

Tunisia 

Paris 

Paris 

Paris 

Paris 


Honolulu 


HOLLAND 


Marx,  Dr.  R., 
*Rochat,  Prof.  G.  F-, 
*Roelofs,  Dr.  Otto, 

Van  der  Hoeve,  Prof.  J., 

Were,  Dr.  H.  I.  M., 

Zeeman,  Prof.  Dr.  W.  P.  C., 


Leiden 

Groningen 

Amsterdam 

Leiden 

Rotterdam 

Amsterdam 


*Floria,  Dr.  Salvatore, 


ITALY 


MEXICO 
*Alonso,  Dr.  Antonio  F., 

Avalos,  Dr.  Enrique, 

Estrada,  Dr.  Antonio  Torres, 

Gonzalez,  Dr.  Jose  de  J., 

Gonzales,  Dr.  Leppoldo, 

Lopez,  Dr.  Fernando, 

Silva,  Dr.  Rafael, 
*Ulises  de  la  Garza,  Dr.  J., 

Velez,  Dr.  Daniel  M., 


*Beraun,  Dr.  Aurelio, 
Calderon,  Dr.  Juan  Luiz, 
Campodonico,  Dr.  E., 
Dammert,  Dr.  Augusto, 


PERU 


Mexico 

Guadalajara 

Mexico 

Guanajuato 

Pueblo 

Mexico 

Mexico 

Saltillo 

Mexico 


Lima 
Lima 
Lima 


PORTO  Rico 


Bernabe,  Dr.  Rafael, 


San  Juan 


10         Members  of  An  International  Congress  of  Ophthalmology 


SCOTLAND 
*Mackay,  Dr.  George, 

Pollock,  Dr.  W.  B.  Inglis, 
*Rowan,  Dr.  John, 

Sinclair,  Dr.  Arthur  H.  H., 

SPAIN 

Amiga,  Dr.  Hermenegildo, 
*Balbuena,  Dr.  Felix  Fernandez, 
*Barraquer,  Dr.  Ignacio, 

Camison,  Dr.  Agustin  A., 

Castresana,  Dr.  Baldomero, 

Marin-Amat,  Dr.  Manuel, 

Menacho,  Dr.  Manuel, 
*Ortin,  Dr.  Galo  Leoz, 

Poyales,  Dr.  Francisco, 

Salterain,  Dr., 

Virgili,  Dr.  Rovirosa, 


*Gullstrand,  Prof.  Allvar, 
*Xordenson,  Dr.  J.  W., 


SWEDEN 


URUGUAY 


Tsola,  Dr.  Almerico, 


Arraiz,  Dr.  A.  Jimenez, 
*Dominici,  Dr.  Santos, 
Espino,  Dr.  U.  M., 


VENEZUELA 


Edinburgh 
Glasgow 
Glasgow 
Edinburgh 


Barcelona 

Gijon 

Barcelona 

Santander 

Madrid 

Almeria 

Barcelona 

Madrid 

Madrid 

Madrid 


Upsala 
Stockholm 


Montevideo 


Caracas 
Caracas 
Caracas 


UNITED  STATES 


Abbott,  W.  J., 
*Abele,  L.  H., 
*Adams,  Chas.  F., 
Adams,  Frederick, 
*Adams,  W.  Herbert, 
Alcorn,  John  B., 
*Alger,  Ellice  M., 
*Allen,  Thos.  D., 
*  Ailing,  Arthur  N., 
Allport,  Frank, 
Anderson,  C.  G., 
Andrews,  Albert  H., 
*Andrews,  James  H., 
Andrews,  Jos.  A., 
*Andrews,  S.  L., 
Arneberg,  J.  G., 
Arnold,  Francis  J., 
Ash,  Arthur  F., 
*Atkinson,  Walter  S., 
Aufmwasser,  H.  W., 
Austin,  J.  W., 


Cleveland,  Ohio 
Chicago,  111. 
Trenton,  N.  J. 
Seattle,  Wash. 
Jacksonville,  Fla. 
Columbus,  Ohio 
New  York  City 
Chicago,  111. 
New  Haven,  Conn. 
Chicago,  111. 
Carbondale,  Pa. 
Chicago,  111. 
Brooklyn,  N.  Y. 
Santa  Barbara,  Calif. 
Lewiston,  Me. 
Grand  Forks,  N.  Dak. 
Burlington,  Vt. 
Weehawken,  N.  J. 
Watertown,  N.  Y. 
Denver,  Colo. 
High  Point,  N.  C. 


Members  of  An  International  Congress  of  Ophthalmology         11 


Austin,  Thos.  C., 
Austin,  Wm.  H., 
Aynsworth,  Horace  T., 
*Ayres,  Wylie  McL., 

Baer,  B.  F.,  Jr., 

Bahn,  Chas., 
*Bailey,  Fred  D., 

Bailey,  F.  W., 
*Bailey,  Harold, 
*Bailey,  Wm.  J., 
*Baker,  Chas.  H., 
*Baker,  H.  B., 

Balentine,  P.  L., 
*Ball,  Dr.  Jas.  M., 
*Bane,  Wm.  C., 
*Banner,  C.  W., 

Barck,  C., 

Barkan,  Adolph, 

Barkan,  Hans, 
*Barker,  O.  G.  A., 

Barrows,  F.  L., 

Beach,  Bennett  S., 
*Beach,  S.  Judd, 
*Beattie,  Robert, 

Beaudoux,  Henry  A., 

Beaumont,  John  F., 

Beatty,  Hugh  G., 
*Beck,  A.  J., 
*Bedell,  Arthur  J., 

Beem,  lone  F., 

Beeman,  C.  E., 
*Begle,  H.  L., 
*Bell,  Geo.  H., 

Bell,  James  H., 

Bell,  M.  H., 
*Benedict,  W.  L., 
*Benson,  Geo.  E., 
*Bentley,  Frederick, 
*Bentley,  Neil, 
*Benton,  Lt.  F.  L., 
*Berens,  Dr.  Conrad,  Jr. 

Binger,  E.  H., 
*Blaauw,  Edmund  E., 

Black,  Howard, 

Black,  Melville, 

Black,  N.  M., 

Blackburn,  W.  J., 
*Blackmar,  F.  B., 
*Blackwell,  Enoch, 
*Blackwell,  Karl  S., 

Blackwood,  Jas.  M., 
*Blair,  Wm.  W., 


Pasadena,  Calif. 
Griffin,  Ga. 
Waco,  Texas 
Cincinnati,  Ohio 

Philadelphia,  Pa. 
New  Orleans,  La. 
Brooklyn,  N.  Y. 
Cedar  Rapids,  Iowa 
Springfield,  Mo. 
Connellsville,  Pa. 
Bay  City,  Mich. 
Taunton,  Mass. 
Philadelphia,  Pa. 
St.  Louis,  Mo. 
Denver,  Colo. 
Greensboro,  N.  C. 
St.  Louis,  Mo. 
San  Francisco,  Calif. 
San  Francisco,  Calif. 
Johnstown,  Pa. 
Moscow,  Idaho 
New  York,  N.  Y. 
Portland,  Me. 
Detroit,  Mich. 
Minneapolis,  Minn. 
Portland,  Ore. 
Columbus,  Ohio 
New  Rochelle,  N.  Y. 
Albany,  N.  Y. 
Chicago,  111. 
Grand  Rapids,  Mich. 
Detroit,  Mich. 
New  York,  N.  Y. 
San  Antonio,  Texas 
Vicksburg,  Miss. 
Rochester,  Minn. 
Minneapolis,  Minn. 
Seattle,  Wash. 
Detroit,  Mich. 
Washington,  D.  C. 
New  York,  N.  Y. 
St.  Paul,  Minn. 
Buffalo,  N.  Y. 
Palo  Alto,  Calif. 
Denver,  Colo. 
Milwaukee,  Wis. 
Dayton,  Ohio 
Columbus,  Ga. 
Trenton,  N.  J. 
Richmond,  Va. 
New  Castle,  Pa. 
Pittsburgh,  Pa. 


12         Members  of  An  International  Congress  of  Ophthalmology 


*Blake,  Eugene  M., 

Blake,  Wm.  F., 
*Bledsoe,  R.  W., 
*Blue,  J.  B.T 

Blum,  H.  N., 
*Boehringer,  H.  W., 

Boiler,  W.  F., 
*Bordley,  James,  Jr., 

Bouvy,  Harry, 
*Branch,  Frederick  D., 

Brasefield,  E.  N., 
*Brawley,  F.  E., 
*Brawley,  R.  V., 
*Bribach,  Eugene  J., 
*Brickley,  W., 
*Briggs,  H.  H, 
*Briggs,  Wm.  E., 
*Brinckerhoff,  E.  E., 

Broderick,  Frank  W., 
*Brose,  L.  D., 
*Broughton,  Wm.  R., 

Brown,  E.  T., 
*Brown,  E.  V.  L., 

Brown,  H.  H., 
*Brown,  J.  C., 
*Brown,  John  E., 

Brown,  Samuel  H., 
*Brown,  W.  E., 

Brownell,  Morton  E., 
*Bruner,  Wm.  E., 

Bruns,  H.  Dickson, 

Bryant,  D.  C., 
*Buchanan,  Mary, 

Buckman,  E.  V., 

Bullard,  Robt.  I., 
*Bulson,  Albert  E., 
*Burch,  F.  C., 
*Burdick,  Austin  F., 
*Burke,  John  W., 
*Butler,  W.  K., 
*Buvinger,  Chas.  W., 

Byrnes,  Harry  F., 

*Calhoun,  F.  Phinizy, 
Cameron,  Howard  McD., 
Camp,  Walter  E., 
Campbell,  Chas.  W., 
Campbell,  Don  M., 

"Campbell,  W.  K., 

*Capron,  F.  P., 

"Carleton,  Ralph, 
Carlin,  C.  H., 
Carpenter,  E.  W., 


New  Haven,  Conn. 
San  Francisco,  Calif. 
Covington,  Ky. 
Memphis,  Tenn. 
New  Orleans,  La. 
Philadelphia,  Pa. 
Iowa  City,  Iowa 
Baltimore,  Md. 
La  Grande,  Ore. 
Binghamton,  N.  Y. 
Phjllipsburg,  N.  J. 
Chicago,  111. 
Salisbury,  N.  C. 
Atchison,  Kans. 
Marion,  Ohio 
Asheville,  N.  C. 
Sacramento,  Calif. 
Oakland,  Calif. 
Sterling,  111. 
Evansville,  Ind. 
New  York,  N.  Y. 
Burlington,  Vt. 
Chicago,  111. 
Chicago,  111. 
Wichita,  Kans. 
Columbus,  Ohio 
Philadelphia,  Pa. 
Pittsburgh,  Pa. 
Oneonta,  N.  Y. 
Cleveland,  Ohio 
New  Orleans,  La. 
Los  Angeles,  Calif. 
Philadelphia,  Pa. 
Wilkes-Barre,  Pa. 
Springfield,  111. 
Ft.  Wayne,  Ind. 
St.  Paul,  Minn. 
Lansing,  Mich. 
Washington,  D.  C. 
Washington,  D.  C. 
East  Orange,  N.  J. 
Springfield,  Mass. 

Atlanta,  Ga. 
Sacramento,  Calif. 
Minneapolis,  Minn. 
Columbus,  Neb. 
Detroit,  Mich. 
Long  Branch,  N.  J. 
Providence,  R.  I. 
Springfield,  Mass. 
Torrington,  Conn. 
Greenville,  S.  C. 


Members  of  An  International  Congress  of  Ophthalmology 


13 


Carpenter,  Forrest  A., 
*Carpenter,  John  T., 

Carr,  Andy  M., 

Carroll,  G.  G., 
*Carroll,  Jas.  J., 
*Carson,  W.  E., 
*Carvill,  Maud, 

Gary,  Edward  H., 
*Cattley,  Stephen  J., 

Cayce,  E.  B., 
*Chamberlain,  W.  P., 
*Chambers,  Talbot  R., 
*Chance,  Burton, 

Chapman,  V.  A., 

Charles,  Jose.  W., 

Chattin,  J.  F., 
*Cheney,  Robert  C., 
*Childers,  Robert  J., 

Childs,  Hal.  A., 
*Christenbery,  H.  E., 

Churchman,  V.  F., 

Claiborne,  John  Herbert, 
*Clapp,  Clyde  A., 

Clark,  C.  F., 

Clark,  J.  Sheldon, 

Clark,  J.  Wendell, 

Clark,  Lloyd  H., 
*Clark,  Newton  T., 

Clayton,  George  R., 

Cleff,  Oscar, 

Clement,  Chas.  C., 

Clement,  L.  O., 

Cline,  B.  McH., 
*Cobb,  Edwin, 

Cochrane,  Wayne  A., 
*Cocklin,  C.  C., 

Cogan,  J.  E., 
*Cohen,  Lee, 
*Cohen,  Louis  L., 
*Cohen,  Martin, 

Collendar,  Major  E.  R., 

Colliver,  Samuel  N., 

Colver,  Benton  N., 
*Compton,  Robt.  F., 

Connor,  Ray, 

Constantine,  K.  W., 

Cook,  F.  S., 

Cook,  W.  Albert, 

Coover,  D.  H., 

Copeland,  R.  C., 

Cordes,  F.  C., 
*Corser,  J.  B., 
*Coulter,  Chas.  F., 


Statesville,  N.  C. 
Philadelphia,  Pa. 
Minot,  N.  D. 
Rochester,  N.  Y. 
Baltimore,  Md. 
Pittsburgh,  Pa. 
Boston,  Mass. 
Dallas,  Texas 
Ogdensburg,  N.  Y. 
Nashville,  Tenn. 
Cleveland,  Ohio 
Jersey  City,  N.  J. 
Philadelphia,  Pa. 
Milwaukee,  Wis. 
St.  Louis,  Mo. 
Newark,  N.  J. 
Boston,  Mass. 
Plainfield,  N.  J. 
Creston,  Iowa 
Knoxville,  Tenn. 
Charleston,  W.  Va. 
New  York,  N.  Y. 
Baltimore,  Md. 
Columbus,  Ohio 
Lexington,  Ky. 
Chicago,  111. 
Rochester,  N.  Y. 
Spartanburg,  S.  C. 
Lima,  Ohio 
Chicago,  111. 
Chicago,  111. 
Grants  Pass,  Ore. 
Milledgeville,  Ga. 
Marshalltown,  Iowa 
Jackson,  Mich. 
Harrisburg,  Pa. 
Cleveland,  Ohio 
Baltimore,  Md. 
Brooklyn,  N.  Y. 
New  York,  N.  Y. 
Washington,  D.  C. 
Seattle,  Wash. 
Battle  Creek,  Mich. 
Charlottesville,  Va. 
Detroit,  Mich. 
Birmingham,  Ala. 
Eau  Claire,  Wis. 
Tulsa,  Okla. 
Denver,  Colo. 
New  York,  N.  Y. 
San  Francisco,  Calif. 
Scranton,  Pa. 
Great  Falls,  Mont. 


14         Members  of  An  International  Congress  of  Ophthalmology 


*Covington,  Maj.  L.  C. 

Cowin,  Carl  C., 
*Cowper,  H.  W., 
*Coyle,  A.  L., 
"Creighton,  W.  J., 
*Crigler,  Lewis  W., 
*Crisp,  Wm.  H., 

Crockett,  R.  L., 

Croman,  Jos.  M., 

Crook,  Martin, 
*Croskey,  John  Welsh, 

Cross,  A.  E., 
*Cross,  G.  H., 
*Curdy,  R.  J., 
*Curran,  E.  J., 
*Curry,  Glendon  E., 
*Curtin,  Thos.  H., 
*Curtis,  Elbert  A.. 

Cutler,  Colman  W., 

*Dailey,  R., 

Dancy,  A.  B., 
*Daugherty,  L.  E., 

Davidson,  Morris, 
*Davis,  A.  Edward, 
*Davis,  Frederick  A., 

Davis,  J.  E., 

Davis,  Ralph  F., 
*Davis,  W.  T., 

Dayton,  G.  O., 
*Dyaton,  W.  L., 

Dean,  F., 

Decker,  John  J., 
*Decker,  P.  H., 

Deery,  Geo.  E., 

Dempsey,  W.  H., 

Denig,  R., 
*Dennis,  D.  N., 
*Derby,  George  S., 
*Dewey,  J.  H., 

Diaz,  Jos.  L., 

Dickson,  John  F., 

Diem,  Oscar, 

Dilworth,  W.  D., 
*Dimitry,  T.  J., 

Dixon,  W.  E., 
*Dodd,  C.  S., 
*Dodd,  Oscar, 

Dolan,  Wm.  E., 

Dolman,  Percival, 

Donavan,  J.  A., 

Donnell,  N.  R., 

Donoher,  W.  D., 


West  Point,  N.  Y. 
Jamestown,  N.  D. 
Buffalo,  N.  Y. 
Wheeling,  W.  Va. 
Philadelphia,  Pa. 
New  York,  N.  Y. 
Denver,  Colo. 
Oneida,  N.  Y. 
Mt.  Clemens,  Mich. 
Spartanburg,  S.  C. 
Philadelphia,  Pa. 
Worcester,  Mass. 
Chester,  Pa. 
Kansas  City,  Mo. 
Kansas  City,  Mo. 
Pittsburgh,  Pa. 
New  York,  N.  Y. 
Newark,  N.  J. 
New  York,  N.  Y. 

Houston,  Texas 
Jackson,  Tenn. 
Cumberland,  Md. 
New  York,  N.  Y. 
New  York,  N.  Y. 
Madison,  Wis. 
McAlester,  Okla. 
Portland,  Ore. 
Washington,  D.  C. 
Butte,  Mont. 
Lincoln,  Neb. 
Council  Bluffs,  Iowa 
New  York,  N.  Y. 
Philadelphia,  Pa. 
Brooklyn,  N.  Y. 
Alton,  111. 
New  York,  N.  Y. 
Erie,  Pa. 
Boston,  Mass. 
Philadelphia,  Pa. 
Newark,  N.  J. 
Portland,  Oregon 
New  York,  N.  Y. 
Pasadena,  Calif. 
New  Orleans,  La. 
Oklahoma  City,  Okla. 
Petersburg,  Va. 
Evanston,  111. 
Worcester,  Mass. 
San  Francisco,  Calif. 
Butte,  Mont. 
St.  Louis,  Mo. 
Salt  Lake  City,  Utah 


Members  of  An  International  Congress  of  Ophthalmology         15 


Dorente,  Dred  R., 

Dorsey,  J.  G., 

Dow,  Frank  E., 
*Dowling,  Jas.  C., 
*Dowling,  Jos.  E., 

Dowling,  J.  Ivimey, 
*Downey,  Jesse  W.,  Jr., 

Drake,  Chas.  A., 
*Driver,  W.  E., 
*Duane,  Alex., 
*Dunn,  Ira  J., 
*Dunn,  Jas.  W., 

Dunnington,  John  H., 

Duntley,  G.  S., 
*Dutrow,  H.  V., 

*Edgar,  T.  O., 

Edgerton,  A.  E., 
*Edmonds,  J.  P., 

Edwards,  Frank  A., 

Edwards,  Slocum  R., 
*Edwards,  Walter, 
*Egan,  B.  W., 
*Ellegood,  J.  A., 
*EUett,  E.  C., 
*Ellingwood,  William, 

Elliott,  W.  F., 
*Ellis,  Bertha  W., 

Ellis,  John  B., 

Emerson,  Linn, 

Engle,  H.  P., 

Ericson,  J.  G., 
*Estabrook,  Chas.  T., 

Evensen,  Harold  O., 
*Ewing,  Arthur  E., 

Faith,  Thomas, 
*Farnsler,  H.  Hershey, 
*Farrior,  J.  Brown, 
*Feingold,  Marcus, 
*Felderman,  Lem., 

Fenton,  Ralph  A., 

Fenton,  Thomas  H., 

Ferguson,  E.  I., 
*Ferguson,  Robt.  J., 
*Ferree,  C.  E., 

Findlay,  E.  K., 
*Finnoff,  Wm.  C., 
*Fisher,  W.  A., 

Fiske,  David 
*Fiske,  George  F., 

Fitzgerald,  F.  J.  C., 
*Fleck,  H.  K., 


Ft.  Smith,  Ark. 
Wichita,  Kans. 
Northampton,  Mass. 
Washington,  D.  C. 
Providence,  R.  I. 
Albany,  N.  Y. 
Baltimore,  Md. 
New  York,  N.  Y. 
Norfolk,  Va. 
New  York,  N.  Y. 
Erie,  Pa. 
Cairo,  111. 
New  York,  N.  Y. 
Bushnell,  111. 
Dayton,  Ohio 

Dixon,  111. 
Taft,  Calif. 
Middlesboro,  Ky. 
Los  Angeles,  Calif. 
Fort  Collins,  Colo. 
Rochester,  N.  Y. 
Logansport,  Ind. 
Wilmington,  Del. 
Memphis,  Tenn. 
Rockland,  Maine 
Lincolnton,  N.  C. 
Lansing,  Mich. 
Chicago,  111. 
Orange,  N.  J. 
Newton,  Iowa 
Minneapolis,  Minn. 
Worcester,  Mass. 
Chicago,  111. 
St.  Louis,  Mo. 

Chicago,  111. 
Harrisburg,  Pa. 
Tampa,  Fla. 
New  Orleans,  La. 
Philadelphia,  Pa. 
Portland,  Oregon 
Philadelphia,  Pa. 
Oklahoma  City,  Okla. 
New  Haven,  Conn. 
Bryn  Mawr,  Pa. 
Chicago,  111. 
Denver,  Colo. 
Chicago,  111. 
Chicago,  111. 
Chicago,  111. 
New  York,  N.  Y. 
Baltimore,  Md. 


16         Members  of  An  International  Congress  of  Ophthalmology 


Forchheimer,  Walter, 

Forgrave,  L.  R., 
*Forster,  A.  E., 

Fowler,  Earle  B., 

Fox,  Chas.  H., 
*Fox,  Frederick  G., 
*Fox,  L.  Webster, 

Fox,  Ralph  D., 

Fox,  Wra.  H., 

Francis,  Charles  H., 
*Francis,  Lee  Masten, 
*Franklin,  Walter  S., 
*Fraser,  R.  C., 
*Frey,  Clarence  L., 
*Fridenwald,  Harry, 
*Friesen,  H.  J., 
*Fringer,  W.  R., 

Frisch,  Frederick, 

Frost,  W.  S., 

Fulkerson,  C.  B., 

Fullenwider,  C.  M., 

Fuller,  Chas.  G., 

Fuller,  John  A., 

Fuller,  T.  O., 
*Fulton,  John  F., 

Gamble,  W.  E., 

Gantt,  L.  Rosa  H., 
*Gardiner,  Edwin  J., 

Garraghan,  Edw.  F., 

Garrison,  Lt.-Col.  F.  H., 

Gavin,  Edward  F., 

George,  Edgar  J., 
*George,  H.  W., 
*Gibson,  Robt.  D., 

Gifford,  Sanford  R., 
*Gilbert,  Frank  Y., 
*Gilbert,  Walter  J., 
*Gill,  George, 
*Gill,  Jas.  J., 
*Gillett,  D.  F., 
*Gillman,  Robt.  W., 
*Gillum,  J.  R., 
*Gittins,  T.  R., 

Glasser,  Edw.  F., 

Gleason,  J.  E., 
*Glover,  S.  P., 
*Goldbach,  L.  J., 

Goldenburg,  Michael, 
*Golding,  Jos.  E., 
*Goldstein,  Isadore, 
*Good,  Wm.  M., 

Goodenow,  N.  H., 


Cincinnati,  Ohio 
St.  Joseph,  Mo. 
Philadelphia,  Pa. 
Chicago,  111. 
Kearney,  Neb. 
Chicago,  111. 
Philadelphia,  Pa. 
Bloomington,  111. 
Washington,  D.  C. 
Chicago,  111. 
Buffalo,  N.  Y. 
San  Francisco,  Calif. 
Port  Huron,  Mich. 
Scranton,  Pa. 
Baltimore,  Md. 
Grand  Forks,  N.  D. 
Rockford,  111. 
Atlantic  City,  N.  J. 
Spokane,  Wash. 
Kalamazoo,  Mich. 
Muskogee,  Okla. 
Chicago,  111. 
Reno,  Nev. 
Texarkana,  Ark. 
St.  Paul,  Minn. 

Chicago,  111. 
Spartanburg,  S.  C. 
Chicago,  111. 
Chicago,  111. 
Washington,  D.  C. 
Waukegan,  111. 
Chicago,  111. 
Middletown,  Pa. 
Youngstown,  Ohio 
Omaha,  Neb. 
Portland,  Me. 
Calais,  Me. 
Elyria,  Ohio 
Baltimore,  Md. 
Syracuse,  N.  Y. 
Detroit,  Mich. 
Terre  Haute,  Ind. 
Sioux  City,  Iowa 
San  Francisco,  Calif. 
Detroit,  Mich. 
Altoona,  Pa. 
Baltimore,  Md. 
Chicago,  111. 
Brooklyn,  N.  Y. 
New  York,  N.  Y. 
Waterbury,  Conn. 
Sierra  Madre,  Calif. 


Members  of  An  International  Congress  of  Ophthalmology        17 


*Goux,  R.  S., 
*Gradle,  Harry  S., 

Graham,  R.  Watson, 

Gratiot,  Harvey  B., 

Green,  Aaron  S., 
*Green,  John,  Jr., 
*Green,  Louis  D., 
*Green,  Louis  S., 

Greene,  R.  A., 
*Greenwood,  Allen, 

Gregory,  A.  R., 
*Griesner,  L.  Lawrence, 
*Griffith,  J.  Beaty, 
*Griscom,  J.  Milton, 

Grosvenor,  Lorenzo  N., 

Grove,  Benj.  H., 
*Gullion,  O.  R., 

Gurley,  Lycurgus  M.( 

Guthrie,  J.  M., 
*Guyer,  Prof.  M.  F., 

Haas,  Frederick  J., 
*Haden,  Henry, 

Haley,  P.  A., 

Hall,  Alfred  M., 
*Hall,  Gaylord  C., 

Hall,  Wm.  P., 

Hallett,  Wayne, 

Hamlin,  Francis  A., 
*Hammett,  Chas.  M., 

Hampton,  Robt.  R., 
*Hancock,  James  C., 

Hansell,  Howard  F., 

Harbert,  John  P., 

Harbridge,  D.  F., 
"Harding,  F.  B., 

Hare,  George  R., 
*Hargitt,  Chas.  A., 

Harkness,  Gordon  F., 
*Harlan,  Herbert, 

Harrington,  A.  F., 

Harris,  C.  M., 
*Harrower,  David, 

Hartshorne,  Isaac, 

Haskell,  Alfred  W., 
*Haskin,  H.  P., 
*Hauer,  A.  M., 

Haughey,  Wilfrid, 

Hay  den,  Austin  A., 

Hazen,  E.  H., 

Hearvy,  John  H., 
"Hebert,  A.  W., 
*Heckel,  Edw.  B., 
2 


Detroit,  Mich. 
Chicago,  111. 
Los  Angeles,  Calif. 
Dubuque,  Iowa 
San  Francisco,  Calif. 
St.  Louis,  Mo. 
San  Francisco,  Calif. 
Washington,  D.  C. 
Spokane,  Wash. 
Boston,  Mass. 
Jacksonville,  111. 
Roselle,  N.  J. 
Washington,  D.  C. 
Philadelphia,  Pa. 
Huron,  S.  D. 
Buffalo,  N.  Y. 
Eugene,  Ore. 
Johnstown,  Pa. 
Meridian,  Miss. 
Madison,  Wis. 

Leavenworth,  Kan. 
Houston,  Texas 
Charleston,  W.  Va. 
Chicago,  111. 
Louisville,  Ky. 
Utica,  N.  Y. 
New  York,  N.  Y. 
Bakersfield,  Calif. 
Washington,  D.  C. 
Salt  Lake  City,  Utah 
Brooklyn,  N.  Y. 
Philadelphia,  Pa. 
Bellefontaine,  Ohio 
Phoenix,  Ariz. 
Allentown,  Pa. 
New  York,  N.  Y. 
Brooklyn,  N.  Y. 
Davenport,  Iowa 
Baltimore,  Md. 
Muskegon,  Mich. 
Johnstown,  Pa. 
Worcester,  Mass. 
New  York,  N.  Y. 
Portland,  Me. 
Williamsport,  Pa. 
Columbus,  Ohio 
Battle  Creek,  Mich. 
Chicago,  111. 
Oakland,  Calif. 
Toledo,  Ohio 
Philadelphia,  Pa. 
Pittsburgh,  Pa. 


18         Members  of  An  International  Congress  of  Ophthalmology 


*Hedges,  Halstead, 

Heeb,  H.  J., 
*Heed,  Chas.  R., 
*Heflebower,  R.  C., 

Heggie,  N.  H., 

Heitger,  J.  D., 
*Heitmuller,  George  H., 
*Henning,  Carl, 

Henninger,  L.  L., 
*Henton,  G.  E., 

Hetrick,  Llewellyn  E., 

Hetzel,  C.  C., 
*Hicks,  Vonnie  M., 
*Hiers,  Jas.  L., 

Higbee,  E.  H., 
"Hilgartner,  H.  L., 
*Hill,  Emory, 
*Hill,  J.  A., 
*Hillegas,  Wm.  M., 

Hitchcock,  W.  Alvan,  Jr., 
*Hitzel,  G.  A., 
*Hoeffler,  C.  L., 

Hoffman,  J.  R., 

Hoffman,  L.  G., 
*Hoffman,  Philip  F., 
*Holloway,  T.  B.. 

Hollyday,  W.  H., 

Hoist,  John, 
*Holt,  E.  E., 
*Holt,  E.  E.,  Jr., 

Holzapfel,  Wm.  H., 
*Holzer,  Wm.  F., 

Hood,  T.  C., 
*Hooker,  Lt.  James  F., 

Hopkins,  Guy  H., 
*Hopper,  W.  L., 

Hosmer,  C.  M., 
*Hough,  Perry  B., 
*Howe,  Lucien, 
*Howland,  F.  A., 
"Hubbard,  H.  V., 

Huber,  L.  H., 
*Hughes,  F.  W., 

Hughes,  H.  S., 

Hulen,  Yard  H., 

Humrichouse,  J.  W., 
*Hunt,  Ella  G., 

Hurley,  Edward  D., 

Ingram,  Lawrence  C., 
*Irwin,  Frank  N., 
*Isaacs,  David, 

Israel,  Jos.  P., 


Charlottesville,  Va. 
Milwaukee,  Wis. 
Philadelphia,  Pa. 
Cincinnati,  Ohio 
Jacksonville,  Fla. 
Louisville,  Ky. 
Washington,  D.  C. 
Washington,  D.  C. 
Council  Bluffs,  Iowa 
Portland,  Ore. 
New  York,  N.  Y. 
Ogden,  Utah 
Raleigh,  N.  C. 
Savannah,  Ga. 
St.  Louis,  Mo. 
Austin,  Texas 
Richmond,  Va. 
Asbury  Park,  N.  J. 
Philadelphia,  Pa. 
Boston,  Mass. 
Buffalo,  N.  Y. 
Everett,  Wash. 
Chicago,  111. 
Chicago,  111. 
White  Plains,  N.  Y. 
Philadelphia,  Pa. 
'Asheville,  N.  C. 
Omaha,  Neb. 
Southern  Pines,  N.  C. 
Portland,  Maine 
New  York,  N.  Y. 
Worcester,  Mass. 
Indianapolis,  Ind. 
Washington,  D.  C. 
Pueblo,  Colo. 
Fort  Scott,  Kans. 
San  Diego,  Calif. 
New  York,  N.  Y. 
Buffalo,  N.  Y. 
Adrian,  Mich. 
Plainfield,  N.  J. 
Livingston,  Mont. 
Indianapolis,  Ind. 
St.  Louis,  Mo. 
San  Francisco,  Calif. 
Hagerstown,  Md. 
Cincinnati,  Ohio 
Boston,  Mass. 

Orlando,  Fla. 
New  York,  N.  Y. 
Omaha,  Neb. 
Houston,  Texas 


Members  of  An  International  Congress  of  Ophthalmology  .       19 


Israel,  N.  E., 
Israel,  Sidney, 

Mack,  Edwin  E., 

*Jackson,  Edward, 

*Jacobi,  Frank, 
Jacobs,  M.  W., 

Macoby,  D.  P.  A., 

*Jameson,  P.  C., 
Jarvis,  C.  C., 

Mean,  George  W., 
Jenne,  Byron  H., 

Mennings,  Chas.  W., 

Mennings,  J.  Ellis, 
Jervey,  J.  W., 
Jessaman,  L.  W., 
Jobson,  George  B., 
Johnson,  Walter  B., 
Johnson,  W.  H., 

Mohnston,  J.  G., 
Johnston,  Wilson, 
Jones,  Arthur  C., 
Jones,  Chas.  J., 

Mones,  E.  L., 

Mones,  Elgin  W., 
Jones,  Fred  W., 

Mones,  L.  Leroy, 
Jordon,  George  T., 

*Kahn,  W.  Randolph, 
*Keeler,  Chas., 
*Keiper,  George  F., 

Kellog,  Francis  B., 
*Kemler,  Jos., 
*Kennon,  B.  R., 
*Kershner,  W.  EL, 
*Key,  Ben  Witt, 

Kiehle,  Frederick  A., 
*Kincaid,  J.  H., 
*King,  Clarence, 
*King,  William  Rufus, 

Kirk,  Albert  W., 

Kirkendale,  John, 

Kirkpatrick,  S., 
*Knapp,  Arnold, 

Knapp,  A.  J., 

Knipe,  J.  C., 
*Knowlton,  L.  G., 

Koller,  Carl 
*Kollock,  Chas.  W., 

Koonce,  S.  E., 

Kraft,  Oscar, 
*Krebs,  Adolph, 


Houston,  Texas 
Houston,  Texas 

Boston,  Mass. 
Denver,  Colo. 
Toledo,  Ohio 
St.  Ixniis,  Mo. 
Newport,  R.  I. 
Brooklyn,  N.  Y. 
Clarksburg,  W.  Va. 
Santa  Barbara,  Calif. 
Detroit,  Mich. 
Pittsburgh,  Pa. 
St.  Louis,  Mo. 
Greenville,  S.  C. 
Framingham,  Mass. 
Franklin,  Pa. 
Paterson,  N.  J. 
Muscatine,  Iowa 
Charlotte,  N.  C. 
Portland,  Ore. 
Butte,  Mont. 
Philadelphia,  Pa. 
Cumberland,  Md. 
Lynn,  Mass. 
Alton,  111. 
Portsmouth,  Va. 
Chicago,  111. 

Baltimore,  Md. 
Darien,  Conn. 
Lafayette,  Ind. 
Los  Angeles,  Calif. 
Baltimore,  Md. 
Norfolk,  Va. 
Bath,  Maine 
New  York,  N.  Y. 
Portland,  Ore. 
Knoxville,  Tenn. 
Cincinnati,  Ohio 
Washington,  D.  C. 
San  Francisco,  Calif. 
Ithaca,  N.  Y. 
Selma,  Ala. 
New  York,  N.  Y. 
Evansville,  Ind. 
Philadelphia,  Pa. 
Cleveland,  Ohio 
New  York,  N.  Y. 
Charleston,  S.  C. 
Wilmington,  N.  C. 
Chicago,  111. 
Pittsburgh,  Pa. 


20        Members  of  An  International  Congress  of  Ophthalmology 


Kress,  George  H., 
*Krieger,  Wm.  A., 
*Krimsky,  S.  Joseph, 
*Krug,  Ernest  F., 
"Kruskal,  J.  D., 

LaForce,  E.  F., 

Lakin,  H.  P., 

Lamb,  Harvey  D., 
*Lamb,  Robert  Scott, 
*Lambardo,  M., 
*Lambert,  W.  E., 

Lamkin,  Burt  B., 
*LaMotte,  W.  O., 
*Lancaster,  Walter  B., 

Landa,  Michael  G., 

Landman,  Otto, 
*Lane,  Frances, 
"Lane,  L.  A., 
*Langdon,  H.  Maxwell, 
*Larkin,  B.  J., 
*Larsen,  Carl  E., 

Lauder,  Clark  H., 
*Lauterbach,  W.  F., 

Lederman,  I.  A., 
*Lee,  Dorothea, 

Lee,  John  W., 
*LeFevre,  S., 

Lefler,  Anna  B., 
*Lemere,  H.  B., 
*Lemoine,  Albert  N., 
*Lent,  E.  J., 

Lester,  John  C., 
*Levy,  Louis, 
*Lewis,  F.  Park, 

Lewis,  W.  W., 
*Libby,  Gecrge, 
*Lichtenberg,  J.  S., 

Lidikay,  Chas.  J., 
"Lilly,  J.  M., 
*Linn,  Jay  G., 

Lippincott,  J.  A., 

Lischkoff,  Mozart, 

Lloyd,  A.  W., 
*Lloyd,  Ralph  I., 
*Loeb,  Clarence, 
*Lokey,  Hugh  M., 
*Long,  Jas.  A., 

Loomis,  E.  A., 
*Looper,  Edward  A., 
*Loring,  Francis  B., 

Love,  J.  King, 
*Love,  Louis  F., 


Los  Angeles,  Calif. 
Poughkeepsie,  N.  Y. 
Brooklyn,  N.  Y. 
New  York,  N.  Y. 
Brooklyn,  N.  Y. 

Burlington,  Iowa 
Lansdale,  Pa. 
St.  Louis,  Mo. 
Washington,  D.  C. 
Brooklyn,  N.  Y. 
New  York,  N.  Y. 
Fresno,  Calif. 
Wilmington,  Del. 
Boston,  Mass. 
New  York,  N.  Y. 
Toledo,  Ohio 
Chicago,  111. 
Minneapolis,  Minn. 
Philadelphia,  Pa. 
Indianapolis,  Ind. 
St.  Paul,  Minn. 
Grinnell,  Iowa 
Dayton,  Ohio 
Ix)uisville,  Ky. 
San  Jos6,  Calif. 
Minneapolis,  Minn. 
Glens  Falls,  N.  Y. 
Los  Angeles,  Calif. 
Omaha,  Neb. 
Boston,  Mass. 
South  Bend,  Ind. 
New  York,  N.  Y. 
Memphis,  Tenn. 
Buffalo,  N.  Y. 
St.  Paul,  Minn. 
Denver,  Colo. 
Kansas  City,  Mo. 
Kansas  City,  Kans. 
Fayetteville,  N.  C. 
Pittsburgh,  Pa. 
Pittsburgh,  Pa. 
Pensacola,  Fla. 
Hammond,  Ind. 
Brooklyn,  N.  Y. 
Chicago,  111. 
Atlanta,  Ga. 
Frederick,  Md. 
Minneapolis,  Minn. 
Baltimore,  Md. 
Washington,  D.  C. 
Easton,  Pa. 
Philadelphia,  Pa. 


Members  of  An  International  Congress  of  Ophthalmology 


21 


Lowell,  W.  Holbrook, 
*Luedde,  W.  H., 
*Lukens,  Chas., 

Lynch,  J.  F., 

Lyon,  Martha  M.  Brewer, 

*McAllister,  J.  C., 

McBride,  Wm.  O., 

McCannell,  Archibald  D., 
*McCaw,  John  A., 
*McClelland,  C.  C., 

McConachie,  A.  D., 
*McConville,  C.  Adeline, 

McCool,  Joseph  L., 

McCoy,  George  W., 

McCubbin,  J.  B., 
*McDannald,  Clyde  E., 

McDonald,  S.  J., 

McDougall,  Jas.  C., 
*McDowell,  George  W., 
*McGuire,  Hunter  H., 
*McHenry,  D.  D., 
*McIntire,  Frederic  J., 

McKee,  Albert  M., 
*McKee,  C.  W., 

McKennan,  Jas.  W., 
*McKimmie,  O.  S., 
*McKinney,  A.  R., 
*McLean,  Wm., 
*McMullen,  Surgeon  John, 
*McMurray,  John  B., 

McPherson,  S.  Dace, 

McQuade,  M.  A., 
*McReynolds,  John  O., 

McWilliams,  J.  M., 

Mackenzie,  Alice  V., 
*Mackenzie,  George  W., 

Macleish,  A.  C., 

Macleish,  A.  L., 

MacMillan,  A.  L.,  Jr., 

*Macnie,  John  S., 

*McKeon,  E.  E., 

Magruder,  A.  C., 

*Mahoney,  Geo., 
Maire,  Lewis  E., 
Maloney,  D.  J., 
Mansur,  Leon  W., 

*Markel,  J.  Clyde, 
Markham,  H.  C., 

*Marlow,  Frank  W., 

*Marsh,  Elias  J., 

'Marshall,  J.  W., 

*Martin,  H.  H., 


Boston,  Mass. 
St.  Louis,  Mo. 
Toledo,  Ohio 
Winona,  Minn. 
South  Bend,  Ind. 

Ridgway,  Pa. 
Fort  Wayne,  Ind. 
Minot,  N.  D. 
Denver,  Colo. 
Detroit,  Mich. 
Baltimore,  Md. 
Brooklyn,  N.  Y. 
Portland,  Ore. 
Los  Angeles,  Calif. 
Fulton,  Mo. 
New  York,  N.  Y. 
Boston,  Mass. 
Atlanta,  Ga. 
New  York,  N.  Y. 
Winchester,  Va. 
Oklahoma  City,  Okla. 
Lynn,  Mass. 
San  Francisco,  Calif. 
Greensburg,  Pa. 
Washington,  Pa. 
Washington,  D.  C. 
Saginaw,  Mich. 
New  York,  N.  Y. 
Washington,  D.  C. 
Washington,  Pa. 
Durham,  S.  C. 
Newburgh,  N.  Y. 
Dallas,  Texas 
Fayetteville,  Tenn. 
Philadelphia,  Pa. 
Philadelphia,  Pa. 
Los  Angeles,  Calif. 
Los  Angeles,  Calif. 
Concord,  N.  H. 
Minneapolis,  Minn. 
Denver,  Colo. 
Colorado  Springs,  Colo. 
Chicago,  111. 
Detroit,  Mich. 
Waterbury,  Conn. 
Los  Angeles,  Calif. 
Pittsburgh,  Pa. 
Parsons,  Kans. 
Syracuse,  N.  Y. 
Paterson,  N.  J. 
Leesburg,  Va. 
Savannah,  Ga. 


22         Members  of  An  International  Congress  of  Ophthalmology 


*Matheny,  R.  C., 
Matison,  E.  A., 
Maxey,  E.  E., 
Maxson,  Sands  C., 

*May,  C.  H., 
May,  Jas.  V., 
Meadows,  D.  F., 

*Meanor,  Wm.  C., 

*Means,  C.  S., 

*Mehl,  Wm., 
Meigs,  R.  J., 

*Mercer,  Wm.  F., 

*Merrill,  H.  G., 
Merritt,  R.  E., 
Mershon,  Oliver  F., 
Mertins,  Paul  S., 

*Metz,  Roy  B., 

*Metzger,  Irvin  D., 
Middleton,  A.  B., 

*Mikell,  Pinkney  V., 

*Miles,  H.  S., 

*Miller,  Clifton  M., 

*Miller,  Edwin  B., 

*Miller,  Frank  K., 
Miller,  Frank  W., 
Millett,  Frank  A., 

*Millette,  John  W., 

*Mills,  Lloyd, 

*Minor,  H.  F., 
Minor,  L.  C., 
Mittendorf,  A.  D., 

*Monaghan,  D.  G., 

*Monson,  S.  H., 

*Moore,  C.  C., 

*Moore,  G.  A., 
Moore,  G.  H., 

*Moore,  J.  D., 

*Moore,  T.  J., 
Moore,  T.  W. 

*Morgan,  A.  D., 

*Morgan,  Browne, 
Morgenroth,  H.  W., 

*Mori,  S., 

'Morrison,  Edw.  L., 
Morse,  A.  W., 
Morsman,  L.  W., 
Morton,  Howard, 
Mott,  John  S., 

*Moulton,  H. 
Moss,  Robt.  E., 
Mullen,  Jos.  A., 

*Muncaster,  S.  B., 

*Mundt,  Henry, 


Galesburg,  111. 
Chicago,  111. 
Boise  City,  Idaho 
Utica,  N.  Y. 
New  York,  N.  Y. 
Marinette,  Wis. 
St.  Louis,  Mo. 
Pittsburgh,  Pa. 
Columbus,  Ohio 
Buffalo,  N.  Y. 
Lowell,  Mass. 
Richmond,  Va. 
Provo,  Utah 
Los  Angeles,  Calif. 
Philadelphia,  Pa. 
Montgomery,  Ala. 
Cleveland,  Ohio 
Pittsburgh,  Pa. 
Pontiac,  111. 
Columbia,  S.  C. 
Bridgeport,  Conn. 
Richmond,  Va. 
Philadelphia,  Pa. 
Philadelphia,  Pa. 
Los  Angeles,  Calif. 
Greenfield,  Mass. 
Dayton,  Ohio 
Los  Angeles,  Calif. 
Memphis,  Tenn. 
Springfield,  Ohio 
New  York,  N.  Y. 
Denver,  Colo. 
Cleveland,  Ohio 
Philadelphia,  Pa. 
Palmer,  Mass. 
Schuylkill  Haven,  Pa. 
Bloomfield,  N.  J. 
Akron,  Ohio 
Huntington,  W.  Va. 
Norfolk,  Va. 
Bloomfield,  N.  J. 
Oshkosh,  Wis. 
Baltimore,  Md. 
Washington,  D.  C. 
Butte,  Mont. 
Hibbing,  Minn. 
Minneapolis,  Minn. 
Kansas  City,  Mo. 
Fort  Smith,  Ark. 
San  Antonio,  Texas 
Houston,  Texas 
Washington,  D.  C. 
Chicago,  111. 
t 


Members  of  An  International  Congress  of  Ophthalmology         23 


Murray,  Alfred  N., 
*Murray,  Wm.  R., 
*Myers,  Dean, 

Myers,  Harry  L.; 

Mytinger,  Geo.  S., 

*Nabers,  Samuel  F., 

Nance,  Willis  O., 
*Nardin,  W.  H., 
*Nebinger,  Reid, 
*Neeper,  Edw.  R., 
*Neher,  Edwin  M., 

Nelson,  Chas.  F., 

Nelson,  Louis,  A. 

Newcomb,  John  R., 
*Newhart,  Horace, 
*Newell,  Wm.  S., 
*Neulen,  E.  Nelson, 

North,  Nelson  L., 
*Norton,  D.  C., 

Noyes,  Guy  L., 
*Nutter,  C.  F., 

Nutting,  R.  J., 

*Oberdorfer,  Archie  L., 
*O'Brien,  John  I., 

O'Brien,  Steve  A., 

O'Brien,  T.  A., 
*O'Connor,  Roderic, 

O'Donnell,  Major  G.  A. 
*Oertel,  T.  E., 
"Offutt,  W.  N., 
*Ohly,  John  H., 
*Orcutt,  D.  C., 
*Overbay,  F.  A., 
*Owen,  Arthur  E., 

Owen,  Frank  S., 

*Paganelli,  Terigi  R., 
*Park,  J.  Walter, 
*Parker,  Walter  R., 

Pasternacki,  B.  W., 

Patterson,  E.  W.  E., 
*Patterson,  W.  E., 
*Patton,  Jas.  M., 
*Payne,  S.  M., 

Peabody,  H.  C., 

Pearson,  Geo.  J., 

Pearson,  W.  W., 

Peery,  Thos.  E., 

Pelle,  Harry  L., 
*Pendexter,  R.  S., 

Perry,  Richard  W., 


Chicago,  111. 
Minneapolis,  Minn. 
Ann  Arbor,  Mich. 
Norfolk,  Va. 
Chillicothe,  Ohio    - 

Birmingham,  Ala. 
Chicago,  111. 
Anderson,  S.  C. 
Danville,  Pa. 
Colorado  Springs,  Colo. 
Salt  Lake  City,  Utah 
Cleveland,  Ohio 
St.  Paul,  Minn. 
Indianapolis,  Ind. 
Minneapolis,  Minn. 
Washington,  D.  C. 
Astoria,  Ore. 
Brooklyn,  N.  Y. 
Manchester,  N.  H. 
Columbia,  Mo. 
Nashua,  N.  H. 
Oakland,  Calif. 

New  York,  N.  Y. 
Schenectady,  N.  Y. 
Mason  City,  la. 
Philadelphia,  Pa. 
San  Francisco,  Calif. 
Fort  Sill,  Okla. 
Augusta,  Ga. 
Lexington,  Ky. 
Brooklyn,  N.  Y. 
Chicago,  111. 
New  Orleans,  La. 
Lansing,  Mich. 
Omaha,  Neb. 

Hoboken,  N.  J. 
Harrisburg,  Pa. 
Detroit,  Mich. 
Detroit,  Mich. 
Grand  Rapids,  Mich.  • 
Minneapolis,  Minn. 
Omaha,  Neb. 
New  York,  N.  Y. 
\Vebster,  S.  D. 
Burlington,  Iowa 
Des  Moines,  Iowa 
Bluefield,  W.  Va. 
Louisville,  Ky. 
Washington,  D.  C. 
Seattle,  Wash. 


24        Members  of  An  International  Congress  of  Ophthalmology 


*Peter,  Luther  C., 
*Peterman,  H.  F., 

Pfingst,  A.  O., 

Phelj)s,  Kenneth  A., 

PhiUips,  Frank  A., 

Phillips,  William  H., 
'Place,  E.  Clifford, 
*Pole,  S.  Boyce, 

Pontius,  Nevin  D., 

Pontius,  Paul, 

Porter,  Edwards  H., 

Porter,  L.  B., 
*Posey,  William  Campbell, 

Post,  Lawrence  T., 

Post,  M.  H., 

Potter,  W.  W., 
*Pratt,  Fred  J., 

Presnell,  C.  W., 
*Price,  N.  W., 
*Prince,  A.  E., 

Procter,  Percy  C., 

Prout,  J.  S., 
*Pusey,  Brown, 
*Pyle,"  Wallace, 
fPyle,  Walter  L., 

*Quackenboss,  Alex., 

*Radcliffe,  McCluney, 

Ralston,  W.  W., 
*Rand,  Prof.  Gertrude, 

Randolph,  Wilson, 

Ravdin,  M., 

Ray,  Victor, 

Reaves,  W.  P., 
*Redding,  Leonard  C., 
*Reed,  Charles  L., 

Reed,  J.  Ross, 

Reeder,  J.  E., 
*Reese,  Robert  G., 

Reger,  Harry  S., 

Reynolds,  H.  G., 
*Rhode,  Homer  J., 
*Rice,  John  E., 

Rideout,  Wm.  J., 

Riker,  John  D., 
*Rindlaub,  Martin  P.,  Jr., 
*Ring,  G.  Oram, 

Ringle,  C.  A., 

Ringueberg,  Eugene, 

Risley,  J.  N., 

Ritter,  Howard  M., 


t  Deceased. 


Philadelphia,  Pa. 
Baltimore,  Md. 
Louisville,  Ky. 
Minneapolis,  Minn. 
Pasadena,  Calif. 
Cleveland,  Ohio 
Brooklyn,  N.  Y. 
Washington,  D.  C. 
Los  Angeles,  Calif. 
Philadelphia,  Pa. 
Tiffin,  Ohio 
Providence,  R.  I. 
Philadelphia,  Pa. 
St.  Louis,  Mo. 
St.  Louis,  Mo. 
Knoxville,  Tenn. 
Minneapolis,  Minn. 
Trinidad,  Colo. 
Niagara  Falls,  N.  Y. 
Springfield,  111. 
Boston,  Mass. 
Fishkill,  N.  Y. 
Chicago,  111. 
Jersey  City,  N.  J. 
Philadelphia,  Pa. 

Boston,  Mass. 

Philadelphia,  Pa. 
Houston,  Texas 
Bryn  Mawr,  Pa. 
Detroit,  Mich. 
Evansville,  Ind. 
Cincinnati,  Ohio 
Greensboro,  N.  C. 
Scranton,  Pa. 
Pittsburgh,  Pa. 
Pasadena,  Calif. 
Sioux  City,  la. 
New  York,  N.  Y. 
Jamestown,  N.  Y. 
Paducah,  Ky. 
Reading,  Pa. 
Worcester,  Mass. 
Freeport,  111. 
Pontiac,  Mich. 
Fargo,  N.  D. 
Philadelphia,  Pa. 
Greeley,  Colo. 
Lockport,  N.  Y. 
New  Bedford,  Mass. 
Williamsport,  Pa. 


Members  of  An  International  Congress  of  Ophthalmology        25 


Robbins,  Elmer  E.,  Jr., 

Robertson,  Edwin  M., 
*Robinson,  H.  T., 

Robinson,  J.  La  Rue, 
*Robinson,  R.  E., 
*Roebuck,  J.  Paul, 
*Rogers,  Robert  H., 

Rogers,  T.  Avery, 
*Rood,  L.  C., 

Rosebrough,  F.  H., 
*Row,  Geo.  S., 

Rowland,  John  F., 
*Rowland,  W.  D., 

Ruby,  Fred  McK., 

Rudolphy,  Jay  Besson, 

Rust,  E.  G., 
*St.  Clair,  Chas.  T., 

Saliba,  Michel, 

Samuels,  Bernard, 

Samuels,  Maimon, 

Sanderson,  Hermon  H., 
*Sargent,  A.  Alonzo, 

Sartain,  Paul  J., 

Sattler,  Robert, 

Sauer,  W.  W., 
*Savage,  Moses  M., 

Sawyer,  W.  W., 

Scarlett,  Hunter  W., 
*Schaeffer,  Prof.  J.  Parsons, 
*Schipfer,  L.  A., 
*Schlichter,  Chas.  H., 

Schlindwein,  G.  Wm., 
*Schlivek,  Kaufman, 

Schoch,  Lester  E., 
*Schoenberg,  Mark  J., 
*Schweinitz,  George  E.  de, 

Schwenk,  Peter  N.  K., 

Scott,  Lewis  M., 
*Sears,  Wm.  H., 

Sedwick,  Wm.  A., 

Seely,  A.  C., 

Seelye,  Walter  K., 
*Seiberling,  Geo.  F., 
*Seibert,  E.  G., 
*Sener,  Walter  J., 
*Sernoffsky,  I., 
*Shackleton,  W.  E., 

Shahan,  W.  E., 

Shanklin,  Eldridge  M., 
*Shannon,  C.  E., 
*Shannon,  John  R., 
*Sharrett,  G.  O., 

Shastid,  Thos.  H., 


New  Bedford,  Mass. 
Concordia,  Kans. 
Cumberland,  Md. 
Reno,  Nev. 
Waverly,  Iowa 
Lancaster,  Pa. 
Newark,  N.  J. 
Plattsburg,  N.  Y. 
Boston,  Mass. 
Brownwood,  Texas 
Indianapolis,  Ind. 
Hot  Springs,  Ark. 
Boston,  Mass. 
Union  City,  Ind. 
Philadelphia,  Pa. 
Cleveland,  Ohio 
Bluefield,  W.  Va. 
Wilson,  N.  C. 
New  York,  N.  Y. 
Seattle,  Wash. 
Detroit,  Mich. 
Philadelphia,  Pa. 
Philadelphia,  Pa. 
Cincinnati,  Ohio 
Marietta,  Ohio 
Baltimore,  Md.  . 

Elizabeth  City,  N.  C. 
Philadelphia,  Pa. 
Philadelphia,  Pa. 
Bismarck,  N.  D. 
Elizabeth,  N.  J. 
Erie,  Pa. 
New  York,  N.  Y. 
Shamokin,  Pa. 
New  York,  N.  Y. 
Philadelphia,  Pa. 
Philadelphia,  Pa. 
Jellico,  Term. 
Huntingdon,  Pa. 
Denver,  Colo. 
Roseburg,  Ore. 
Seattle,  Wash. 
Allentown,  Pa. 
Washington,  D.  C. 
Philadelphia,  Pa. 
Buffalo,  N.  Y. 
Cleveland,  Ohio 
St.  Louis,  Mo. 
Hammond,  Ind. 
Philadelphia,  Pa. 
New  York,  N.  Y. 
Cumberland,  Md. 
Superior,  Wis. 


26         Members  of  An  International  Congress  of  Ophthalmology 


*Sherman,  Elbert  S., 
Shields,  Jas.  M., 
Shine,  Francis  W.. 
*Shoemaker,  J.  F., 
Shoemaker,  W.  A., 
*Shoemaker,  Wra.  T., 
*Shreve,  Owen  M., 
*Shultz,  Louis  A., 
Shuman,  G.  H., 
*Shumway,  E.  A., 
*Shute,  D.  K., 
*Siegel,  Francis  X., 
*Simonds,  Otis  F., 
*Simpson,  J.  H., 
Simpson,  W.  Likely, 
Sims,  W.  S., 
*Singleton,  E.  M., 
*Skeel,  H.  Robertson, 
*Skirball,  Jos.  J., 
*Slataper,  Felician  J., 
*Sleight,  R.  D., 
*Sliteler,  C.  I., 
*Sloan,  Henry  L., 
*Slocum,  Geo., 
*SmaU,  Chas.  P., 
*Smart,  Frank  P., 
Smith,  Arthur  E., 
Smith,  Carroll, 
Smith,  Chas.  L., 
Smith,  Dean  S., 
*Smith,  Borland, 
*Smith,  E.  Terry, 
*Smith,  George, 
*Smith,  George  M., 
Smith,  Harry  A., 
Smith,  Henry  M., 
*Smith,  H.  Reginald, 
Smith,  Josiah  E., 
Smith,  Owen  A., 
Smith,  S.  S., 
*Smith,  Victor  C., 
*Smyth,  P.  Somers, 
Sneed,  Carl  M., 
*Snell,  Albert  C., 
*Snyder,  Walter  H., 
*Souter,  W.  N., 
Spalding,  Fred  M., 
Spalding,  James, 
*Spencer,  Frank  R., 
*Spangler,  John  A., 
*Spiegelglass,  A.  B., 
Spratt,  Chas.  N., 
Stahlman,  Fred  C., 


Newark,  N.  J. 
Denver,  Colo, 
New  York,  N.  Y. 
St.  Louis,  Mo. 
St.  Louis,  Mo. 
Philadelphia,  Pa. 
Erie,  Pa. 
Rockford,  111. 
Pittsburgh,  Pa. 
Philadelphia,  Pa. 
Washington,  D.  C. 
Cincinnati,  Ohio 
Cleveland,  Ohio 
Louisville,  Ky. 
Memphis,  Tenn. 
Jackson,  Miss. 
Marshalltown,  Iowa 
New  York,  N.  Y. 
Boston,  Mass. 
Philadelphia,  Pa. 
Battle  Creek,  Mich. 
Chester,  Pa. 
Charlotte,  N.  C. 
Ann  Arbor,  Mich. 
Chicago,  111. 
Norfolk,  Va. 
Minneapolis,  Minn. 
Spokane,  Wash. 
Independence,  Kans. 
LaCrosse,  Wis. 
Bridgeport,  Conn. 
Hartford,  Conn. 
Casper,  Wyo. 
Rome,  Ga. 
Delta,  Colo. 
Brooklyn,  N.  Y. 
Chicago,  111. 
Charleston,  S.  C. 
Farmington,  Mo. 
Pittsburgh,  Pa. 
New  Orleans,  La. 
Boston,  Mass. 
Columbia,  Mo. 
Rochester,  N.  Y. 
Toledo,  Ohio 
Portsmouth,  N.  H. 
Boston,  Mass. 
Portland,  Me. 
Boulder,  Colo. 
Geneva,  N.  Y. 
Hackensack,  N.  J. 
Minneapolis,  Minn. 
Charleroi,  Pa. 


Members  of  An  International  Congress  of  Ophthalmology         27 


Stanford,  J.  B., 
Standish,  Myles, 

*Stark,  H.  H., 

*Stark,  Jesse  B., 
Starr,  Elmer  G., 

*Stauffer,  J.  Leaver, 
Steese,  Edwin  S., 

*Stegman,  L.  B., 
Steim,  Jos.  M., 
Steinfeld,  A.  C., 
Stephens,  W.  B., 

*Sternberg,  Jos.  E., 
Steuber,  F.  G., 
Stevenson,  D.  W., 
Stieren,  Edw., 
Stillwell,  Hiram  R., 
Stockard,  Cecil, 

*Stone,  H.  B., 
Stookey,  W.  M., 
Strader,  Geo.  L., 

*Strickler,  David  A., 
Strout,  Eugene  S., 
Stuart,  Chas.  C., 

*Stucky,  J.  A., 
Sturm,  S.  A., 
Suffa,  G.  A., 
Suker,  George  F., 
Sulzer,  Gustavus  A., 

*Sulzman,  Frank  M., 
Sutherland,  Fred  B., 
Sutphin,  Theron  Y., 

*Swab,  Chas.  M., 

*Swan,  C.  J., 
Sweet,  Robert  B., 

*Sweet,  William  M., 
Swift,  Geo.  W., 

*Tarun,  William, 
Taylor,  Joseph  W., 

*Taylor,  Lewis  H., 

Tenner,  A.  S., 
Tenney,  John  A., 

*Theobald,  Samuel, 
Thigpen,  Chas.  A., 

*Thomas,  Frances  W., 
Thomas,  Jerome  B., 
Thompson,  P.  H., 
Thomson,  Edgar  S., 
Thomson,  John  J., 

*Thorpe,  Harvey  E., 

*Tibbens,  Clyde  E., 

Tibbet,  Albert, 

Tilderquist,  D.  L., 


Memphis,  Tenn. 
Boston,  Mass. 
El  Paso,  Tex. 
New  York,  N.  Y. 
Buffalo,  N.  Y. 
Philadelphia,  Pa. 
New  York,  N.  Y. 
Battle  Creek,  Mich. 
New  Kensington,  Pa. 
Toledo,  Ohio 
Alameda,  Calif.     ^ 
Boston,  Mass. 
Lima,  Ohio 
Akron,  Ohio 
Pittsburgh,  Pa. 
Denver,  Colo. 
Atlanta,  Ga. 
Roanoke,  Va. 
Salt  Lake  City,  Utah 
Cheyenne,  Wyo. 
Denver,  Colo. 
Minneapolis,  Minn. 
Cleveland,  Ohio 
Lexington,  Ky. 
Pittsburgh,  Pa. 
Boston,  Mass. 
Chicago,  111. 
Columbus,  Ohio 
Troy,  N.  Y. 
New  York,  N.  Y. 
Newark,  N.  J. 
Philadelphia,  Pa. 
Evanston,  111. 
Long  Beach,  Calif. 
Philadelphia,  Pa. 
Seattle,  Wash. 

Baltimore,  Md. 
Tampa,  Fla. 
Wilkes-Barre,  Pa. 
New  York,  N.  Y. 
Boston,  Mass. 
Baltimore,  Md. 
Montgomery,  Ala. 
Columbus,  Ohio 
Palo  Alto,  Calif. 
Boston,  Mass. 
New  York,  N.  Y. 
Mt.  Vernon,  N.  Y. 
Pittsburgh,  Pa. 
Washington,  Pa. 
Washington,  D.  C. 
Duluth,  Minn. 


28        Members  of  An  International  Congress  of  Ophthalmology 


"Tingley,  Louise  P., 

"Tomassene,  Raymond  A., 
Torney,  S.  J., 
Townsend,  C.  E., 
Trimble,  Clarence  S., 
Tripp,  Ira  A., 
Troncoso,  M.  Uribe, 

"Tuckerman,  W.  C., 

*Tuckerman,  W.  H., 

*Turner,  Hunter  H., 

*r£|pner,  Oliver  W., 
lydings,  Oliver, 

"Tyson,  Henry  H., 

Upham,  Helen  F., 
*Urner,  M.  H., 

*Vail,  Derrick  T., 
*VanHorn,  Alfred, 

VanKirk,  V.  E., 

•Varick,  Wm.  R., 
*Veasey,  Clarence  A., 
"Verhoeff,  F.  H., 
*Virden,  John  E., 

Vinsonhaler,  F., 

Voigt,  C.  B., 

VonColditz,  G.  Thomson, 
*Von  der  Heydt,  Robert, 


Boston,  Mass. 
Wheeling,  W.  Va. 
Bellingham,  Wash. 
Akron,  Ohio 
Emporia,  Kans. 
Cleveland,  Ohio 
New  York,  N.  Y. 
Cleveland,  Ohio 
Cleveland,  Ohio 
Pittsburgh,  Pa. 
Augusta,  Me. 
Chicago,  111. 
New  York,  N.  Y. 

Asbury  Park,  N.  J. 
Cincinnati,  Ohio 

Cincinnati,  Ohio 
Plainfield,  N.  J. 
Pittsburgh,  Pa. 
Manchester,  N.  H. 
Spokane,  Wash. 
Boston,  Mass. 
New  York,  N.  Y. 
Little  Rock,  Ark. 
Mattoon,  111. 
Chicago,  111. 
Chicago,  111. 


*Wagner,  Carl  B., 
*Waldeck,  George  M., 
Walker,  Arthur  W., 
Walker,  C.  E., 
Walker,  Herbert, 
Walter,  Will, 
*Waltz,  F.  D., 
Wandless,  Henry  W., 
Walker,  Clifford  B., 
Wanamaker,  A.  T., 
Ward,  G.  Harold, 
Warner,  Garden  F., 
*Washburn,  John  S., 
*Watson,  Henry  D., 
*Watson,  J.  A., 
*Watson,  R.  S., 
Weaver,  E.  W., 
Weaver,  T.  W., 
*Webster,  David  H., 
*Weed,  Harry  M., 
*Weeks,  John  E., 
*Weeks,  Webb  W., 
*Weidler,  W.  B., 


Chicago,  111. 
Detroit,  Mich. 
Riverside,  Calif. 
Denver,  Colo. 
Chicago,  111. 
Evanston,  111. 
Detroit,  Mich. 
New  York,  N.  Y. 
Springfield,  Mass. 
Seattle,  Wash. 
Englewood,  N.  J. 
Washington,  D.  C. 
Youngstown,  Ohio 
Binghamton,  N.  Y. 
Minneapolis,  Minn. 
Saginaw,  Mich. 
Akron,  Ohio 
Wichita,  Kans. 
New  York,  N.  Y. 
Buffalo,  N.  Y. 
New  York,  N.  Y. 
New  York,  N.  Y. 
New  York,  N.  Y. 


Members  of  An  International  Congress  of  Ophthalmology         29 


Weih,  E.  P., 
*Weill,  N.  J., 
*Weimer,  E.  S., 

Weiss,  Louis, 
*Weisser,  Edw.  A., 
*Wells,  David, 

Welsh,  D.  E., 
*Werts,  C.  M., 
*Wescott,  C.  D., 

Whaley,  E.  M., 
*Wheeler,  J.  M., 
*Wherry,  W.  P., 
*Whisnant,  A.  M., 
*Whitaker,  Joel, 

White,  Chas.  P., 
*White,  Jas.  W., 
*White,  Jos.  A., 
*Whitman,  Lloyd  B., 
*Wible,  Elmer  E., 
*Wiener,  Alfred, 
*Weiner,  Meyer, 

Wilbur,  Edw.  P., 
*Wilder,  W.  H., 
*Wilkinson,  Oscar, 

Williams,  Kent  E., 
*Wilmer,  William  H., 

Wilson,  Alpheus  K., 
*Wilson,  Edgar  A., 
*Wilson,  Harold, 
*Wilson,  N.  L., 

Wilson,  R.  C., 
*Winter,  Geo.  E., 

Winter,  John  A., 
*Wise,  Ralph  C., 

Wolfe,  Claude  T., 
*Wolff ,  Julius, 

Wolfner,  Henry  L., 

Wood,  Casey  A., 

Wood,  Douglas, 
*Wood,  Hilliard, 

Wood,  J.  Scott, 

Woodruff,  F.  E., 

Woodruff,  H.  W. 

Woodruff,  Thos.  A., 
*Woods,  Hiram, 

Woods,  R.  H., 

Woodson,  J.  M., 
*Worrell,  J.  P., 

Wright,  C.  L., 

Wright,  John  R., 
*Wright,  J.  W., 
'Wright,  R.  H., 

Wiirdemann,  Harry  V., 


Clinton,  Iowa 
Pittsburgh,  Pa. 
Pittsburgh,  Pa. 
Newark,  N.  J. 
Pittsburgh,  Pa. 
Boston,  Mass. 
Grand  Rapids,  Mich. 
Des  Moines,  Iowa 
Chicago,  111. 
Columbia,  S.  C. 
New  York,  N.  Y. 
Omaha,  Neb. 
Charlotte,  N.  C. 
Indianapolis,  Ind. 
Wilmington,  Del. 
New  York,  N.  Y. 
Richmond,  Va. 
Baltimore,  Md. 
Pittsburgh,  Pa. 
New  York,  N.  Y. 
St.  Louis,  Mo. 
Kalamazoo,  Mich. 
Chicago,  111. 
Washington,  D.  C. 
Rome,  N.  Y. 
Washington,  D.  C. 
Jacksonville,  Fla. 
Meriden,  Conn. 
Detroit,  Mich. 
Elizabeth,  N.  J. 
Ithaca,  N.  Y. 
Jackson,  Mich. 
Duluth,  Minn. 
Mansfield,  Ohio 
Louisville,  Ky. 
New  York,  N.  Y. 
St.  Louis,  Mo. 
Chicago,  111. 
Minneapolis,  Minn. 
Nashville,  Tenn. 
Brooklyn,  N.  Y. 
St.  Louis,  Mo. 
Joliet,  111. 

New  London,  Conn. 
Baltimore,  Md. 
La  Salle,  111. 
Temple,  Texas 
Terre  Haute,  Ind. 
Minneapolis,  Minn. 
Louisville,  Ky. 
Columbus,  Ohio 
Richmond,  Va. 
Seattle,  Wash. 


30         Members  of  A  n  International  Congress  of  Ophthalmology 


Wyatt,  O.  W., 
*Wylie,  C.  B., 

*Yost,  Walter  M., 

*Young,  B.  F., 
Young,  H.  B., 
Young,  Thomas  H., 
Yudkin,  Arthur  M., 

*Zehnder,  A.  Charles, 
*Zentmayer,  William, 
*Ziegler,  S.  Lewis, 
*Ziporkes,  Joseph, 
*Zvaifler,  N., 


Manning,  Iowa 
Morgantown,  W.  Va. 

Rochester,  Pa. 
Knoxville,  Tenn. 
Burlington,  Iowa 
New  Haven,  Conn. 
New  Haven,  Conn. 

Newark,  N.  J. 
Philadelphia,  Pa. 
Philadelphia,  Pa. 
New  York,  N.  Y. 
Newark,  N.  J. 


OPENING  SESSION,  APRIL  25,  1922 

HALL  OF  THE  DAUGHTERS  OF  THE  AMERICAN  REVOLUTION 

THE  Congress  was  opened  by  the  Chairman  of  the  Committee 
on  Arrangements,  Dr.  W.  H.  Wilmer,  of  Washington,  D.  C. 
The  following  address  of  welcome  was  then  made  by  Hon.  Cal- 
vin D.  Coolidge,  Vice-President  of  the  United  States: 

ADDRESS  OF  WELCOME 

Mr.  Chairman,  Members  and  Guests  of  the  Congress:  At  the  request 
of  your  Chariman  I  have  the  privilege  of  extending  to  you  a  word  of 
greeting  and  of  welcome.  You  are  meeting  in  the  capital  of  the 
United  States  of  America,  in  a  city  that  bears  the  name  of  a  great 
world  figure,  dedicated  to  stability,  to  civilization,  and  to  liberty.  You 
are  gathered  this  morning  in  the  national  headquarters  of  a  society 
which  for  the  past  represents  patriotism,  and  for  the  present  represents 
the  determination  to  support  and  maintain  civil  government.  There 
are  six  governments  officially  represented  here,  several  universities 
and  scientific  societies,  many  delegates  from  different  countries,  many 
delegates  from  different  portions  of  our  own  nation.  You  are  holding 
this  conference  for  mutual  instruction,  mutual  help,  for  the  alleviation 
of  human  suffering,  educating  each  other,  for  men  do  not  educate 
themselves — by  exchange  of  ideas,  by  consultation,  study  and  con- 
•ference  they  educate  each  other  in  the  arts  and  sciences  and  the 
humanities. 

You  have  come  here  on  an  errand  of  mercy,  desiring  to  make  your 
contribution  to  the  alleviation  of  human  suffering.  You  have  come  in 
the  interests  of  good  health,  which  is  of  great  economic  value  as  well 
as  ministering  to  human  comfort.  As  a  national  asset  there  is  nothing 
of  more  value  than  sound  public  health.  If  you  were  to  strike  down 
all  of  those  things  which  make  up  our  civilization,  our  organizations, 
our  institutions  of  learning,  our  arts  and  our  sciences,  the  last  thing 
with  which  humanity  would  part  would  be  the  asset  of  good  health. 
With  that  remaining,  it  would  be  possible  to  reconstruct  all  else ;  with 

31 


32  An  International  Congress  of  Ophthalmology 

that  gone,  everything  else  that  men  hold  of  value  would  of  necessity 
perish. 

You  have  taken  for  your  province  the  care  and  maintenance  of  the 
eye,  one  of  the  most  wonderful  and  most  delicate  organs  of  the  five 
human  senses,  one  which  makes  the  greatest  contribution  to  human 
intelligence,  for  if  the  philosophers  are  right,  that  perfection  of  subject 
depends  upon  perfection  of  object,  then  the  contribution  that  is  made 
to  the  perfection  of  mankind  through  a  clear  and  accurate  eyesight  is 
one  of  the  greatest  contributions  made  from  any  human  source.  The 
old  Greeks  understood  the  problem.  In  their  language  the  perfect  of 
"to  see"  is  the  present  of  "to  know,"  for  with  them,  as  with  us,  to 
have  seen  means  to  know.  "  If  therefore  thine  eye  be  single,  thy  whole 
body  shall  be  full  of  light."  I  recall  that  during  my  grammar  school 
days  among  the  sentences  in  the  old  school-book  given  me  to  learn 
something  of  the  importance  and  the  use  of  language,  there  was  this 
sentence,  which  has  remained  with  me  always — a  sentence  full  of 
meaning,  full  of  inspiration,  especially  to  those  who  follow  your  pro- 
fession— "The  eye  is  the  window  of  the  soul." 

But  in  addition  to  this  you  come  with  the  broader,  more  extended 
purpose  of  scientific  investigation.  The  world  is  turning  to  science  as 
its  refuge,  as  the  source  of  its  direction  and  as  the  means  of  its  progress. 
You  come  as  ministers  to  the  truth,  determined  to  follow  it  wherever 
it  may  lead,  and  it  is  under  that  principle  that  all  the  world,  all  nations 
and  all  men,  are  drawing  together  with  a  common  purpose.  You  are 
uplifters  of  mankind,  ministering  to  the  general  welfare  of  civilization. 
You  follow  the  truth.  In  the  words  of  my  old  preceptor,  who  never 
tired  telling  those  who  came  under  his  direction  and  his  instruction, 
"Truth  and  Freedom — Truth  coming  from  distinct  sources,  and 
Freedom  knowing  no  bounds  but  those  which  Truth  has  set." 

That  represents  you,  that  represents  civilization,  that  represents 
the  standards  of  today  and  the  hope — the  eternal  hope — of  the  morrow. 

Dr.  E.  C.  Ellett,  Dr.  Cassius  D.  Wescott,  and  Dr.  Clarence  A.  Veasey 
were  appointed  a  Committee  to  Nominate  Permanent  Officers  of  the 
Congress. 

The  Secretary  called  the  roll  of  the  official  delegates  in  the  alpha- 
betic order  of  their  respective  governments,  with  the  request  that  each 
delegate  present  his  credentials. 

CHINA: — Dr.  T.  M.  Li  (Peking  Union  Medical  College): 

It  is  indeed  a  great  pleasure  to  me  to  be  able  to  attend  this  Inter- 
national Congress  that  is  being  held  in  the  capital  city  of  this  great 
country.  I  consider  it  a  great  pleasure  and  honor  to  be  able  to  meet 


Address  of  Foreign  Delegates  33 

so  many  eminent  ophthalmologists  of  this  world  who  have  devoted 
their  lives  to  the  conservation  of  vision.  I  come  from  a  country  in 
which  the  science  of  ophthalmology  is  still  in  its  infancy.  It  is  my 
hope  that  some  day  we  shall  be  able  to  extend  to  you  an  invitation  to 
hold  your  session  like  this  in  my  country.  I  bring  you  greetings  from 
China  and  wish  you  the  success  which  I  have  no  doubt  you  will  have. 

CUBA: — Prof.  C.  E.  Finlay,  Havana: 

I  beg  to  extend  greetings  of  the  Republic  of  Cuba  to  her  northern 
neighbor,  the  great  Republic  in  whose  beautiful  capital  we  meet  this 
morning,  and  to  whom  we  are  united  by  the  bonds  of  lasting  gratitude 
for  the  great  moral  and  material  support  they  extended  to  us  during 
our  war  for  independence;  next,  to  the  members  of  this  Congress, 
meeting  for  the  first  time  in  fifteen  years,  and  after  the  untimely  inter- 
ruption in  1914.  I  wish  to  express  the  hope  that  this  meeting  may 
be  a  contribution,  a  material  advance  in  the  particular  branch  of 
medicine  in  which  we  are  interested. 

FRANCE: — Prof.  F.  de  Lapersonne  (Academic  de  Medecine  de  Paris; 
Faculte  de  Medecine  de  Paris) : 

Au  nom  de  1'Academie  de  Medecine  de  Paris,  au  nom  de  la  Faculte1 
de  Medecine  et  de  Monsieur  le  Ministre  de  1'Instruction  Publique, 
j  'adresse  mon  respectueux  hommage  a  Monsieur  le  President  des  Etats- 
Unis  d'Amerique,  et  mon  salut  le  plus  cordial  aux  membres  du 
Comite  d'organisation  du  Congres  d'ophtalmologie. 

J'apporte  egalement  les  vifs  regrets  de  beaucoup  d'ophtalmologistes 
frangais,  qui  n'ont  pu  se  rendre  a  Washington  a  cause  de  la  distance  et 
des  difficultes  materielles  de  1'heure  presente,  mais  qui  sont  de  tout 
coeur  avec  vous. 

Us  ont  delegue  aupres  de  vous  un  de  leurs  doyens  d'age  qui,  a 
defaut  d'autre  merite,  a  celui  d'etre  profondement  convaincu  de 
1'importance  de  la  mission  que  vous  accomplissez.  Nos  reunions 
periodiques,  dont  vous  avez  si  heureusement  renoue  le  cycle,  marquent 
d'une  pierre  blanche  les  progres  accomplis  par  notre  science  ophtal- 
mologique,  mais  elles  ont  aussi  pour  but  de  rapprocher  des  hommes 
dignes  de  se  comprendre  et  par  consequent  de  s'aimer. 

Salut  et  honneur  au  Congres  International  d'Ophtalmologie  de 
Washington. 

GREAT  BRITAIN: — Mr.  Edward  Treacher  Collins  (Royal  College  of 
Surgeons;  Royal  College  of  Physicians): 

On  behalf  of  the  British  ophthalmologists,  and  of  the  Royal  College 
of  Surgeons  of  England,  and  the  Royal  College  of  Physicians  of  Lon- 
3 


34  An  International  Congress  of  Ophthalmology 

don,  I  wish  to  express  our  indebtedness  to  the  American  Ophthal- 
mological  Society,  the  Section  on  Ophthalmology  of  the  American 
Medical  Association,  and  the  American  Academy  of  Ophthalmology 
and  Oto-Laryngology  for  having  initiated  this  great  Congress.  I  hope 
at  a  subsequent  meeting  to  present  an  invitation  that  will  help  to  pro- 
mote the  continuity  of  such  assemblies  as  this  for  the  promotion  of  our 
special  branch  of  the  profession  and  for  the  consolidation  and  advance 
of  the  friendship  of  all  ophthalmologists. 

HOLLAND: — Prof.  G.  F.  Rochat  (Professor  of  Ophthalmology,  Univer- 
sity of  Groningen;  President  of  the  Ophthalmological  Society  of 
The  Netherlands) : 

I  have  the  honor  to  represent  a  country  whose  history  has  been 
closely  connected  with  the  earliest  history  of  the  United  States,  and 
we  are  very  proud  of  the  fact  that  a  little  trace  of  our  blood  runs  in  the 
veins  of  so  many  of  your  most  prominent  men.  Therefore  the  Gov- 
ernment of  Holland  has  been  very  glad  to  send  their  representative  to 
this  Congress.  We  are  very  eager  to  make  scientific  relations  between 
our  nations  still  more  cordial  than  they  have  ever  been,  and  as  a  repre- 
sentative of  my  country  and  of  the  Ophthalmological  Society  of 
Holland  I  wish  to  bring  you  their  greetings.  We  wish  to  thank  the 
committee  of  this  Congress  for  their  kind  invitation  and  to  express  the 
hope  that  this  Congress  will  serve  the  purpose  of  promoting  ophthal- 
mology in  particular,  science  in  general,  and  better  relations  between 
the  different  nations  in  the  future. 

ITALY: — Dr.  Salvatore  Floria,  of  Washington,  D.  C.: 

I  thank  you  for  your  kind  invitation  to  be  one  of  this  illustrious 
scientific  body.  I  bring  to  you  the  greetings  of  the  Italian  Govern- 
ment and  best  wishes  for  the  success  of  this  conference. 

PERU: — Dr.  Aurelio  Beraun: 

I  have  the  honor  to  be  in  this  country  to  attend  this  great  gathering 
of  eminent  ophthalmologists  of  the  United  States  and  of  the  countries 
of  Europe,  and  it  is  a  great  honor  to  me. 

SPAIN: — Dr.  F.  Poyales  (Faculty  of  Medicine,  Central  University, 
Madrid) : 

Espana  me  envia  a  la  gran  nacion  Americana,  en  representacion  de 
todos  los  oculistas  espanoles,  las  oculistas  Norte-Americanos  han 
invitado  a  un  ilustre  oftalmologo  Espanol  el  Dr.  Barraquer  para 
mostrar  sus  procedimientos  operatorios,  he  de  unir  al  saludo  en- 
tusiasta  a  todos  los  Congresistas  del  Internacional  de  Oftalmologia 


Address  of  Foreign  Delegates  35 

en  Washington,  nuestro  proposito  de  colaboracion  al  progreso  de  la 
cicucia  oftalmologica  en  favor  de  la  humanidad. 

SWEDEN: — Prof.  Allvar  Gullstrand,  Upsala: 

The  Swedish  Government,  by  sending  an  official  delegate  to  this 
Congress,  has  shown  how  it  appreciates  the  high  level  of  scientific  re- 
search and  of  medical  and  ophthalmological  work  in  this  country.  I 
came  here  with  high  expectations,  but  I  must  tell  you  that,  having 
been  here  for  a  couple  of  weeks,  I  have  learned  and  seen  so  much,  I  have 
found  the  level  so  high  and  all  the  colleagues  so  friendly,  that  I  have 
gotten  a  mighty  impression  of  this  country.  I  want  again  to  con- 
gratulate the  United  States  on  having  such  a  staff  of  scientific  oph- 
thalmologic  men. 

BELGIUM: — Prof.    Emile    Gallemaerts    (University    de    Bruxelles; 
Societe  Beige  d'Ophtalmologie) : 

I  shall  take  the  opportunity  offered  by  this  occasion  to  say  a  few 
words  of  thanks  for  the  welcome  you  have  given  us.  Belgium  had  the 
honor  of  first  proposing  the  organization  of  An  International  Congress 
of  Ophthalmology,  and  I  now  have  the  honor  of  bringing  the  saluta- 
tion of  the  Belgians  to  your  noble  and  generous  country.  The  diffi- 
culties which  you  had  to  meet  in  the  organization  of  this  meeting  did 
not  discourage  you;  the  number  of  subscribers,  the  list  of  announced 
communications,  prove  that  success  has  resulted  from  your  effort. 
This  success  shows  the  necessity  of  international  meetings .  After  being 
side  by  side  for  the  defense  of  justice,  honor,  and  humanity,  we  shall 
meet  each  other  hand  to  hand  in  science  and  work  in  the  same  way  for 
the  progress  of  our  beloved  specialty.  Let  us  hope  that  this  meeting, 
which  will  mark  a  new  milestone  in  the  history  of  ophthalmology,  will 
be  the  starting-point  of  a  long  series  of  meetings  which  will  never 
again  be  interrupted.  • 

SCOTLAND: — Dr.  George  Mackay  (Vice-President,  representing  Royal 
College  of  Surgeons,  Edinburgh) : 

I  have  come  a  long  way,  but  I  do  not  propose  to  detain  you  for 
many  minutes.  I  gladly  take  the  opportunity  you  afford  me,  sir,  to 
convey  to  you  from  the  most  ancient  medical  corporation  of  the 
British  Isles,  the  Royal  College  of  Surgeons  of  Edinburgh,  founded  in 
1505,  their  hearty  greetings  and  congratulations  on  your  great  effort 
to  revive  once  more  these  important  international  meetings.  Our 
warmest  sympathies  go  out  to  you,  and  we  feel  confident  that  this  will 
reorganize  once  more  those  friendly  and  helpful  meetings  which  meant 
so  much  for  the  progress  of  ophthalmology. 


36  An  International  Congress  of  Ophthalmology 

BRAZIL. — Dr.  Cesario  de  Andrade  and  Dr.  Pimental  Franco  (Facul- 
dade  de  Medicina  da  Bahia,  Sociedade  Medica  dos  Hospitan  da 
Bahia,  Brazil). 

ARGENTINE: — Dr.  Francisco  J.  Soriano  (Asociacion  Medica  Argen- 
tina) . 

Lt.-Col.  F.  H.  Garrison,  Army  Medical  Corps,  United  States;  Lt. 
James  F.  Hooker,  Navy  Medical  Corps,  United  States;  Surgeon 
John  McMullen,  Public  Health  Service,  United  States. 

REPORT  OF  COMMITTEE  ON  NOMINATIONS 

The  Committee  on  Nominations  submitted  the  following  names  as 
permanent  officers  of  the  Congress: 
President : 

DR.  GEORGE  E.  DE  SCHWEINITZ,  Philadelphia,  Pa. 
Vice-Presidents : 

DR.  FRANCISCO  J.  SORIANO,  Argentine. 

PROF.  EMILE  GALLEMAERTS,  Belgium. 

DR.  CESARIO  DE  ANDRADE,  Brazil. 

DR.  PIMENTAL  FRANCO,  Brazil. 

DR.  T.  M.  Li,  China. 

PROF.  C.  E.  FINLAY,  Cuba. 

DR.  WILLIAM  Z.  HONS,  Czecho-Slovakia. 

MR.  E.  TREACHER  COLLINS,  England. 

PROF.  F.  DE  LAPERSONNE,  France. 

PROF.  G.  F.  ROCHAT,  Holland. 

DR.  SALVATORE  FLORIA,  Italy. 

DR.  AURELIO  BERAUN,  Peru. 

DR.  GEORGE  MACKAY,  Scotland. 

PROF.  IGNACIO  BARRAQUER,  Spain. 

DR.  D.  FRANCISCO  POYALES,  Spain. 

PROF.  ALLVAR  GULLSTRAND,  Sweden. 

DR.  LUCIEN  HOWE,  United  States. 

DR.  EDWARD  JACKSON,  United  States. 

DR.  SANTOS  DOMINICI,  Venezuela. 

Secretary-Treasurer : 

DR.  LUTHER  C.  PETER,  Philadelphia,  Pa. 
Secretaries : 

DR.  ALBERT  LASALLE,  Montreal,  Canada — French. 

DR.  FRANCISCO  M.  FERNANDEZ,  Havana,  Cuba — Spanish. 

DR.  JESUS  M.  PENICHET,  Havana,  Cuba — French  and  Spanish. 


Salutatory  of  President  of  the  Congress  37 

Upon  motion  of  Dr.  E.  C.  Ellett  the  report  was  adopted  and  the 
officers  declared  unanimously  elected. 

The  President  of  the  Congress  was  then  introduced  by  the  Chair- 
man of  the  Committee  on  Arrangements. 

Ladies  and  Gentlemen  of  the  Congress :  In  high  appreciation  of  the 
honor  conferred,  and  with  a  keen  sense  of  the  responsibilities  involved, 
I  beg,  in  representative  capacity  and  personally,  to  extend  a  hearty 
welcome  to  all  here  assembled;  and  to  convey  to  the  Chairmen  and 
members  of  the  Committees  heartfelt  thanks,  in  which,  I  am  sure,  all 
now  gathered  together  freely  join,  for  their  insistent,  unselfish  and 
admirable  work,  which  has  been  translated  into  effective  results  of 
which  we  are  the  happy  beneficiaries.  If  success  shall  be  our  portion, 
it  will  be  due,  not  to  any  one  man  or  group  of  men,  but  to  the  fine 
spirit  of  loyalty  which  has  pervaded  all  men  and  all  women,  who, 
striving  in  perfect  sympathy  and  uncontending  equity,  have  made 
possible  this  Congress  of  ophthalmologists  assembled  for  the  purpose 
of  interchange  of  scientific  thought,  and  the  presentation  of  the  results 
of  research  and  of  clinical  observation. 

For  you,  gentlemen,  who  have  come  from  afar  (I  have  it  not  in  my 
heart  to  say  from  foreign  countries,  for  by  your  very  presence  here 
you  permit  us  to  erase  that  word  from  our  vocabulary) — for  you  con- 
freres, colleagues  and  friends,  I  desire  to  sound  a  special  note  of  wel- 
come, and  to  reveal  to  you  our  sense  of  deep  obligation  in  that  you  are 
with  us.  From  the  clinics  and  laboratories  of  the  countries  of  the  old 
world  we  of  this  new  world  have  drawn  a  rich  income — the  support  of 
our  scientific  existence.  Our  debt  is  large;  we  happily  acknowledge  it; 
we  gladly  owe  it.  We  hope  only  that  we  have  not  been,  and  shall  not 
be,  either  unworthy  or  unmindful  of  these  benefits. 

We  are  glad  because  from  the  Far  East,  from  the  great  Province  on 
our  north,  from  the  countries  to  the  south  of  us,  and  from  our  Island 
neighbor,  representatives  have  come  and  joined  with  us  in  this  enter- 
prise, and  to  them  we  extend  our  grateful  welcome. 

Ladies  and  Gentlemen  of  the  Congress,  believing  that  I  express  our 
united  hopes,  I  trust  we  may  so  respect  our  material  that  it  shall  leave 
our  hands  finished  with  the  master's  touch ;  that  as  we  proceed  along 
the  road  of  scientific  effort  our  feet  shall  neither  stumble  nor  hesitate ; 
and  that  great  success  shall  attend  us  in  all  our  endeavors. 


SCIENTIFIC  PAPERS  AND  ADDRESSES 


DES  ENSEIGNEMENTS  DE  LA  GUERRE  EN 
"  CHIRURGIE  OCULAIRE 

PROFESSEUR  F.  DE  LAPERSONNE 

Paris,  France 

La  Guerre  mondiale,  en  nous  appelant  a  soigner  un  nombre  con- 
siderable de  blesses,  nous  a  permis  de  mettre  a  Pepreuve  et  de  juger 
sous  un  angle  nouveau  les  methodes  chirurgicales  que  nous  avons 
employees  jusqu'alors.  Places  le  plus  souvent  dans  des  conditions 
tres  defavorables,  nous  avons  du  nous  adapter  au  milieu  dans  lequel 
nous  soignions  nos  blesses.  D'autre  part  le  contact  journalier  avec 
les  Chin  irgiens  nous  a  permis  de  comparer  leurs  methodes  nouvelles 
et  d'en  faire  une  large  application. 

Je  voudrais  presenter  au  Congres  International  d'Ophtalmoiogie 
quelques  observations  qui  m'ont  ete  suggerees  par  la  pratique  de  plus 
de  qualre  ans  de  guerre  et  qui  resument  plusieurs  travaux  publics 
avec  nos  Collegues  Franc,  ais.  Je  serais  heureux  si  cette  modeste 
contribution  devenait  le  point  de  depart  d'une  discussion  dans  la- 
quelle  les  Ophtalmologistes  eminents,  reunis  dans  ce  Congres, 
venaient  nous  apporter  le  fruit  de  leur  pratique  chirurgicale  des 
blessures  orbito-oculaires,  et  si  nous  pouvions  ainsi  etablir  le  bilan 
des  progres  accomplis. 

Un  premier  fait,  qui  domine  la  chirurgie  oculaire  de  guerre,  et  que 
nous  retrouverons  dans  les  grands  traumatismes  du  temps  de  paix, 
c'est  que  les  effets  de  ces  traumatismes  sont  rarement  localises  a 
Poeil  ou  a  Porbite,  qu'ils  dejmssent  beaucoup  notre  habituel  domaine 
et  qu'ils  produisent  de  vastes  delabrements  cutanes,  des  fractures 
compliquees  du  crane  et  des  cavite"s  de  la  face  avec  corps  Strangers 
plus  ou  moins  volumineux. 

Toutes  ces  blessures  imposent  une  decision  prompte  et  des  inter- 
ventions graves  et  dedicates  dont  Pophtalmologiste  doit  prendre  la 
direction  avec  Passistance  du  chirurgien  et  de  Potorhinologiste. 
Dans  les  services  militaires  que  j  'ai  diriges,  comme  dans  les  formations 
sanitaires  de  Pavant,  j'ai  toujours  preconise  ces  collaborations  qui 
nous  ont  ete  precieuses. 

39 


40  F.  DE  LAPERSONNE 

La  variete"  des  blessures  orbito-oculaires  est  telle  qu'elles  se  pretent 
mal  a  une  classification.  On  peut  cependant  e"tablir  quelques  cate- 
gories ayant  leurs  indications  distinctes. 

Ce  sont  d'abord  les  plaies  craniofaciales  avec  vastes  delabrements 
cutane"s  des  paupieres  et  des  regions  periorbitaires  mettant  a  nu  les 
os  de  la  face  et  du  crane  avec  fractures  esquilleuses  et  enfoncement. 
Ou  bien  la  peau  est  a  peine  dechire'e,  mais  on  voit  une  tumefaction 
considerable  de  la  region  orbitaire  et  des  parties  voisines,  une  ex- 
ophtalmie  tre"s  marquee  avec  coloration  noiratre  des  teguments 
due  a  de  vastes  he*matomes,  le  tout  souille  par  du  sang  caille",  de  la 
terre  ou  des  corps  Strangers  des  plus  divers. 

Derrie're  ces  teguments  profondement  contus,  des  fractures  multi- 
ples interessent  les  parois  orbitaires.  Par  ordre  de  frequence  on 
rencontre:  1.  Les  fractures  multiples  de  1'os  malaire,  donnant  une 
crepitation  en  sac  de  noix,  avec  irradiations  vers  1'apophyse  zygo- 
matique,  le  maxillaire  superieur  ou  1'apophyse  orbitaire  externe.  2. 
Les  fractures  du  maxillaire  superieur  avec  enfoncement  du  sinus 
maxillaire.  3.  Les  fractures  du  rebord  supe"rieur  de  1'orbite,  ve"rita- 
bles  fractures  de  la  base  du  crane  avec  toutes  leurs  consequences.  4. 
Les  fractures  supero-internes  interessant  les  sinus  frontaux  et  eth- 
moidaux. 

Les  corps  Strangers  orbitaires  plus  ou  moins  volumineux  sont,  en 
outre  des  balles,  des  Eclats  d'obus  ou  de  schrapnells,  des  fragments 
les  plus  vane's  entrained  par  Pe'clatement  du  projectile.  Parmi  les 
plus  curieux  que  j'ai  observes  je  citerai  le  cas  d'une  bague  en  cuivre 
de  detonateur,  mesurant  six  centimetres  de  diametre,  brise"e  en  deux 
demi  anneaux,  1'un  etait  implante  transversalement  dans  les  deux 
orbites  en  arriere  de  la  racine  du  nez,  Fautre  etait  enfonce"  verticalement 
dans  1'orbite  gauche  et  le  sinus  maxillaire.  On  trouve  e"galement  des 
corps  Strangers  beaucoup  plus  petits,  difficiles  a  repe"rer  par  la  radio- 
graphie  ou  par  1'electro-aimant,  dont  la  recherche  dans  1'orbite  est 
d'autant  plus  delicate. 

Au  milieu  de  ces  de*sordres,  1'oeil  est  plus  ou  moins  atteint.  Une 
violente  contusion  sans  de*chirure  de  la  coque  oculaire  peut  produire 
de  grosses  he*morragies,  des  d4collements  de  la  re" tine  ou  la  luxation 
du  cristallin.  A  cette  cate"gorie  de  contusions  semblaient  appartenir 
ces  petites  hemorragies  r^tiniennes,  discretes,  localise'es  au  pole  pos- 
t^rieur  et  a  la  macula,  produites  par  des  contusions,  avec  ou  sans 
fracture  du  rebord  orbitaire  supe*ro-externe,  suivant  un  me'canisme 
dont  M.  Lagrange  a  bien  d^gage"  les  lois.  A  peine  visibles  a  1'oph- 


Enseignements  de  la  Guerre  en  Chirurgie  Oculaire  41 

talmoscope,  elles  ont  cependant  des  consequences  assez  graves  sur 
la  vision. 

Parmi  les  plaies  pene'trantes,  tantot  il  s'agit  d'un  veritable  eclate- 
ment  du  globe,  dont  il  ne  reste  que  des  debris  de  membranes  au  milieu 
de  caillots;  tantot  il  y  a  une  plaie  penetrante  plus  ou  moins  irreguliere, 
sclero-corneenne  ou  poste"rieure,  avec  des  de"sordres  masques  par 
1 'epanchement  sanguin  presque  total;  tantot  enfin  la  plaie  est  tres 
petite,  a  peine  visible. 

Les  corps  etrangers  penetrant  dans  la  cavite  oculaire  a  la  faveur 
de  ces  plaies  sont  d'un  volume  tres  variable.  Mais  une  mention  toute 
spe"ciale  doit  etre  reservee  aux  petits  eclats  intra-oculaires  sur  les- 
quels  j'ai  attire  1'attention  avec  plusieurs  de  mes  collegues.  Fre- 
quemment  observes  pendant  la  guerre  de  tranchee  et  dans  les  com- 
bats a  la  grenade,  ils  penetrent  par  une  plaie  a  peine  visible  et  vite 
cicatrisee.  Uniques  ou  multiples,  magnetiques  ou  parcelles  de  bois, 
de  pierre  ou  de  verre,  leur  gravite  est  grande.  En  raison  de  la  diffi- 
culte  de  leur  reperage  par  la  radiographie  et  des  epreuves  negatives 
par  1'electro-aimant,  ils  ne  peuvent  pas  toujours  etre  extraits  im- 
mediatement  et  ils  entrainent  des  iridocyclites  plastiques  avec  tout 
au  moins  perte  fonctionnelle  et  atrophie  du  globe. 

C'est  pour  cette  categoric  de  blessures  que  nous  avons  ete  obliges 
de  faire  le  plus  d'enucleations  secondaires,  afin  d'eviter  1'ophtalmie 
sympathique. 

Sans  plaie  penetrante,  de  petits  eclats  s'incrustent  sur  la  surface 
corneo-conjonctivale,  produisant  une  reaction  violente,  meme  apres 
ablation  methodique  et  soins  antiseptiques.  Peu  de  jours  apres  il 
peut  survenir  une  iridocyclite  tres  douloureuse  qui  entraine  la  perte 
de  1'oeil.  On  pense  a  la  penetration  meconnue  de  quelques  petits 
eclats,  ou  si  1'autre  peil  a  etc*  atteint,  on  conclut  a  une  ophtalmie 
sympathique.  Quelques  faits  suivis  avec  soin  me  permettent  de  dire 
qu'il  n'en  est  rien.  C'est  particulierement  dans  les  eclats  d'obus  ou 
de  mines  a  courte  distance,  lorsque  la  face  et  les  yeux  sont  cribles  de 
poudre  et  de  petits  eclats,  que  Ton  voit  se  produire  ce  phenomene. 
Deja  il  y  a  plus  de  30  ans,  etant  a  Lille,  j'avais  observe  des  faits 
analogues  chez  des  mineurs  a  la  suite  de  coup  de  grisou,  et  j'avais 
emis  1'hypothese  que  sous  1'influence  de  la  commotion  violente  pro- 
duite  par  le  deplacement  d'air,  il  se  faisait  des  hemorragies  inter- 
stitielles  du  tractus  uveal  favorisant  la  production  de  1'iridocyclite. 
Ce  que  nous  savons  aujourd  'hui  des  graves  alterations  cellulaires 


42  F.  DE  LAPERSONNE 

dans  le  choc  traumatique,  nous  permettent  de  mieux  expliquer  la 
production  de  ces  iridocyclites  fatales  sans  plaie  penetrante. 


Dans  ces  diffe"rents  traumatismes  quelles  sont  les  complications  les 
plus  fre"quentes  que  nous  avons  a  craindre? 

Ce  que  je  viens  de  dire  des  irradiations  des  fractures  vers  le  crane, 
fait  preVoir  que  les  plus  immediatement  redoutables  sont  les  menin- 
gites,  et  les  meningo-encephalites  traumatiques.  Nous  avons  observe 
plusieurs  cas  dont  Involution  a  ete  tres  differente.  Tantot  la  menin- 
gite  etait  suraigiie  avec  elevation  considerable  de  la  temperature, 
delire,  contractures  et  convulsions,  bientot  suivis  de  coma.  La  mort 
survenait  au  bout  de  deux  ou  trois  jours;  a  1'autopsie  on  trouvait  une 
forte  injection  meningee,  un  aspect  louche  de  la  pie-mere  a  la  base, 
mais  pas  de  pus.  Tantot  la  meningo-encephalite  avait  une  allure 
plus  insidieuse;  apres  un  debut  violent,  les  phenomenes  paraissaient 
s'amender,  mais  il  persistait  de  la  cephalee  avec  raideur  de  la  nuque 
et  sou  vent  un  ecoulement  intermittent  de  liquide  cephalo-rachidien ; 
la  courbe  thermometrique  presentait  de  grandes  oscillations  avec 
periodes  de  torpeur,  de  somnolence  faisant  suite  a  1'excitation,  un 
amaigrissement  rapide  se  produisait  et  la  mort  survenait  au  bout  de 
trois  ou  quatre  semaines,  et  meme  plus  tard.  Tantot  enfin  des  inter- 
ventions heureuses  permettaient  d'obtenir  la  guerison  des  blesses 
paraissant  les  plus  gravement  atteints  mais  ils  conservaient  pendant 
longtemps  des  troubles  cerebraux,  et  ils  se  sont  comportes  depuis 
comme  des  trepanes. 

En  opposition  avec  les  grandes  complications  observees  dans  les 
blessures  des  membres  et  du  tronc,  le  tetanos  cephalique  a  ete  tres 
rare  grace  a  1'emploi  precoce  et  tres  large  du  serum  preventif  anti- 
tetanique.  Nous  ne  connaissons  pas  de  cas  de  gangrene  gazeuse  dans 
les  plaies  craniofaciales. 

Les  blessures  orbito-oculaires  sont  rarement  infectees  primitive- 
ment  par  les  corps  etrangers,  nous  n 'avons  suivi  que  trois  blesses 
chez  lesquels  des  fragments  de  vetements,  d'etoffe  ou  de  cuir,  avaient 
ete  entraines  dans  1'orbite;  il  se  produisait  des  cellullites  orbitaires 
avec  ecoulement  tres  fetide,  e"tat  general  grave.  Ils  finirent  cepen- 
dant  par  gue>ir  avec  des  cicatrices  irregulieres. 

L'inf  ection  de  ces  plaies  est  le  plus  sou  vent  secondaire ;  elle  est  due 
au  pneumocoque,  ce  qui  n'est  pas  6tonnant  en  raison  des  larges  com- 
munications des  plaies  orbitaires  avec  les  fosses  nasales  et  les  sinus. 
Elle  est  due  egalement  au  staphylocoque  et  surtout  au  streptocoque. 


Enseignements  de  la  Guerre  en  Chirurgie  Oculaire  43 

Chez  les  nombreux  blesses  qui  nous  ont  ete  envoye"s  au  debut  de  la 
guerre,  plusieurs  jours  et  meme  plusieurs  semaines  apres  le  trauma- 
tisme,  nous  avons  observe  frequemment,  apres  la  chute  des  escarres  et 
dans  la  longue  periode  de  suppuration,  des  erysipeles  et  des  lymphan- 
gites.  Malgre  1'apparente  gravite  de  ces  complications  au  debut,  la 
terminaison  a  ete  favorable,  mais  des  recidives  se  sont  produites, 
entrainant  finalement  des  cicatrices  etendues,  rendant  plus  difficile 
une  restauration  prothetique.  Contre  ces  complications  le  per- 
manganate de  potasse,  1'eau  oxygenee,  les  solutions  hydrargyriques, 
employees  tout  d'abord,  ne  nous  ont  donne  que  de  mediocres  resultats, 
les  differents  serums  polyvalents  ont  eu  des  fortunes  diverses,  c'est  en 
somme  les  hypochlorites  sous  forme  de  liquide  de  Dakin  ou  de  solution 
de  chloramine,  tres  facilement  toleres  par  la  conjonctive  et  les  tissus 
de  la  face,  qui  nous  ont  donne  une  plus  grande  satisfaction. 

La  complication  locale  la  plus  redoutee  des  blessures  oculaires 
devait  etre  I'ophtalmie  sympathique.  Ce  que  nous  savions  par  les 
statistiques  des  guerres  anterieures,  aussi  bien  que  par  les  accidents 
de  travail  du  temps  de  paix,  devait  eveiller  de  grandes  craintes  et 
nous  faire  penser  qu'elle  serait  frequente. 

II  n'en  fut  rien,  heureusement;  1'iridocy elite  sympathique  etaient 
rarement  signalee  dans  les  premieres  annees  de  la  guerre,  si  bien  qu'on 
alia  jusqu'a  la  considerer  comme  negligeable  et  ne  justifiant  pas  des 
operations  aussi  mutilantes  que  1'enucleation. 

Une  statistique  basee  sur  39  cas,  communiques  par  les  chefs  des 
centres  militaires  ophtalmologiques  et  publiee  par  M.  Morax  en 
1917,  vint  remettre  les  choses  au  point;  chacun  de  nous  d'ailleurs  ob- 
servait  dans  le  meme  temps  des  ophtalmies  sympathiques  dues  a 
des  plaies  par  accidents  industriels.  Les  principales  conclusions 
tirees  de  cette  statistique  etaient  que  le  caractere  des  blessures,  la 
presence  ou  1' absence  d'eclats  intra-oculaires,  ne  paraissaient  avoir 
aucune  influence  sur  1'evolution  de  I'ophtalmie  sympathique,  et  que 
pour  etre  preventive,  1'enucleation  devait  etre  pratiquee  dans  les 
quinze  jours  qui  suivaient  1' infection  du  globe  oculaire.  Toutes  les 
operations  partielles  devaient  e"tre  rejetees  lorsqu'il  yavait  acraindre 
ces  accidents.  Une  observation  de  M.  Kalt  montre  qu'une  e'visce'ra- 
tion,  pratiquee  quatre  jours  apres  le  traumatisme,  n'avait  pas  empeche 
les  accidents  du  cote  oppose.  L'ophtalmie  sympathique  etait 
d'ailleurs  assez  sou  vent  benigne  et  dans  plusieurs  observations  on 
signalait  une  grande  amelioration  par  1'emploi  du  neoarse"nobenzol. 

Jusqu'a  la  fin  de  la  Guerre  les  conclusions  rassurantes  de  M.  Morax 


44  F.  DE  LAPERSONNE 

sont  resides  exactes  dans  leur  ensemble,  toutefois  dans  quelques  cas 
isoles  on  a  signale  que  1'ophtalmie  sympathique  avait  eclate  quatre 
jours  apres  la  blessure  (Chaillous). 

Si  1'on  compare  Penorme  frequence  des  blessures  oculaires  avec 
le  petit  nombre  d'ophtalmies  sympathiques  constatees,  on  peut  con- 
clure  que  cette  redoutable  complication  a  £t6  reellement  tres  rare. 
Cette  rarete"  est  due  en  partie  aux  enucleations  parfois  tres  pre"coces 
et  atypiques  que  des  chirurgiens  non  spe"cialistes  ont  pratique"es  aux 
ambulances  du  front,  surtout  au  de"but  de  la  campagne.  Les  soins 
plus  judicieux  donnas  ensuite  par  des  ophtalmologistes  ont  beaucoup 
contribue  a  eViter  ce  danger.  Comme  il  y  a  lieu  de  le  prevoir  ce 
n'est  pas  dans  les  vastes  eclatements  du  globe  ou  dans  les  panophtal- 
mies  que  1'ophtalmie  sympathique  a  ete  constatee,  elle  a  ete  surtout 
observe'e  dans  les  plaies  penetrantes  avec  petits  e"clats  intra-oculaires. 


Le  traitement  des  blessures  orbito-oculaires  a  beneficie  au  cours  de 
la  Guerre  de  grandes  ameliorations  sur  lesquelles  je  demande  la  per- 
mission d'insister  maintenant. 

Au  de*but  la  plupart  des  blesses  arrivant  trop  tardivement  dans  les 
services  d'ophtalmologie,  nous  avons  du  nous  contenter  de  lutter 
centre  1'infection  par  les  pansements  antiseptiques,  le  drainage, 
Pextraction  des  corps  Strangers,  des  fragments  osseux,  1'enucleation 
retardee.  Ce  traitement  aboutissait  a  des  cicatrications  vicieuses  et 
necessitait  plus  tard  des  operations  plastiques  qui  obviaient  plus  ou 
moins  aux  mutilations  de  la  face. 

Des  que  les  conditions  d'installation  dans  les  hopitaux  de  1'avant, 
ou  les  evacuations  plus  rapides  sur  1'Interieur  Font  rendu  possible, 
nous  avons  applique  dans  la  plus  large  mesure  le  traitement  chirurgi- 
cal  precoce  des  plaies  orbito-oculaires. 

La  methode  des  sutures  primitives,  preconisee  par  M.  Gaudier, 
prenait  dans  le  traitement  des  grands  traumatismes  de  guerre,  une 
place  de  plus  en  plus  importante  malgre  quelques  oppositions.  Plus 
que  dans  toute  autre  region  elle  devait  avoir  son  application  dans  la 
chirurgie  craniofaciale,  en  raison  de  la  rarete"  des  infections  primitives 
et  de  la  plus  grande  vitality  des  tissus;  et  de  fait  c'est  cette  methode 
qui  nous  a  rendu  le  plus  de  services  et  a  comple'tement  transforme 
les  resultats.  Quelques  publications  francaises  ont  signale  ces  faits, 
je  citerai  ma  communication  a  1' Academic  de  Medecine  en  Decembre 
1918  et  Texcellent  livre  sur  TOphtalmologie  de  guerre  de  mes  col- 
laborateurs  MM.  Duverger  et  Velter,  paru  en  1919. 


Enseignements  de  la  Guerre  en  Chirurgie  Oculaire  45 

Je  crois  devoir  rappeler  que  le  traitement  precoce  comprend: 

I.  Une  exploration  methodique  de  la  blessure  permettant  de  se 
rendre  compte  non  seulement  des  lesions  superficielles  mais  surtout 
de  1'etendue  des  desordres  profonds,  interessant  les  cavites  peri- 
orbitaires.     C'est  dire  qu'on  doit  toujours  avoir  recours  a  un  examen 
radiologique  complet,  radioscopique  et  radiographique,  avec  les  pro- 
cedes  les  plus  exacts  de  reperage  des  corps  etrangers.     Elle  comprend 
egalement  1'emploi  constant  de  Pelectro-aimant,  la  nature  des  corps 
etrangers  ne  p*ouvant  etre  prevue. 

II.  L'anesthesie  devra  etre  locale  a  de  tres  rares  exceptions  pres. 
Des  instillations  de  cocaine  a  4%  (quatre  pour  cent)  seront  reservees 
pour  les  explorations  superficielles  de  la  conjonctive.     II  faut  tou- 
jours avoir  recours  a  1'anesthesie  par  les  injections  de  novocaiine  a 
quatre  pour  cent,  en  y  ajoutant  deux  ou  trois  gouttes  d'adrenaline  au 
millieme  par  centimetre  cube. 

Les  injections  seront  retro-oculaires  ou  profondes,  passant  en 
arriere  du  globe  et  venant  inonder  le  tissu  adipeux  de  1'orbite  dans  la 
region  du  ganglion  ciliaire;  elles  atteindront  au  sommet  de  1'orbite 
les  nerfs  nasal,  frontal  et  lacrymal;  elles  iront  toucher  le  nerf  maxil- 
laire  superieur  a  sa  sortie  du  trou  sous-orbitaire;  des  injections  sous 
conjonctivales  et  de  veritables  barrages  sous  cutanes  completeront 
I'anesthe'sie  totale  de  1'orbite  et  des  regions  voisines  qui  sera  obtenue 
apres  dix  ou  quinze  minutes.  Je  n'insiste  pas  sur  la  technique 
speciale  qui  a  ete  parfaitement  decrite  par  le  Prof.  Duverger  (de 
Strasbourg). 

Pour  nous  1'anesthesie  locale  a  presque  completement  remplace 
1'anesthesie  generale  par  le  chloroforme,  1'^ther,  le  chlorure  d'ethyle 
ou  le  protoxyde  d'azote.  Depuis  la  Guerre,  dans  un  service  de 
Clinique  aussi  actif  que  celui  de  1'Hotel-Dieu  de  Paris,  c'est  a  peine  si 
nous  avons  recours  deux  ou  trois  fois  par  an  a  1'anesthesie  generale, 
tant  pour  les  operations  douloureuses  de  la  chirurgie  oculo-orbitaire 
que  pour  le  traitement  des  blessures.  La  quantity  de  novocame 
employee,  meme  pour  les  anesthesies  les  plus  difficiles,  larges  auto- 
plasties  ou  exenterations  orbitaires  pour  grosses  tumeurs,  est  tres 
inf erieure  aux  doses  indiqu6es  pour  la  chirurgie  generale ;  nous  savons 
d'ailleurs  que  la  toxicite  de  la  novocame  est  faible.  D'autre  part  il 
est  a  peine  besoin  de  dire  que  cette  anesthesie  fait  disparaitre  toute 
crainte  de  shock  pour  des  sujets  plus  ou  moins  deprimes  ou  atteints 
d'affections  organiques. 

L'anesthesie  a  la  novocai'ne  est  plus  difficile  a  obtenir  lorsque  les 


46  F.  DE  LAPERSONNE 

tissus  sont  enflamme's;  il  faut  quelquefois  attendre  plus  de  vingt 
minutes  avant  de  pouvoir  intervenir  et  Poperation  est  souvent 
douloureuse;  a  plus  forte  raison  lorsqu'il  existe  des  fusees  purulentes 
et  des  complications  dont  il  est  difficile  de  connaitre  les  limites. 
Pour  le  phlegmon  de  1'orbite  par  exemple,  il  n'est  guere  possible  de 
recourir  a  I'anesth^sie  locale.  Ceci  est  une  nouvelle  raison  en  faveur 
du  traitement  precoce  des  blessures  orbito-oculaires. 

III.  Les  blessures  interessant  le  globe  devront  6tre  abordees  par 
la  voie  palpebro-conjonctivale  et  la  conduite  sera,  'bien  entendu, 
differente  suivant  le  cas. 

Je  rappelerai  seulement  quelques  principes: 

1.  La  recherche  et  1'extraction  des  plus  petits  corps  Strangers  intra- 
oculaires  devront  etre  extremement  precoces.     Nous  savons  par  les 
traumatismes  industriels  que  les  degres  de  reussite  et  de  conservation 
de  la  vision  est  en  raison  inverse  du  temps  ecoule  depuis  la  blessure. 
On  ne  peut  done  indiquer  aucune  limite  et  la  latitude  de  quarante 
huit  heures,  assignee  pour  certaines  blessures,  est  ici  beaucoup  trop 
grande.     La  tolerance  relative  pour  les  corps  etrangers  est  souvent 
trompeuse  et  nous  avons  cite  plusieurs  exemples  de  petits  eclats  intra- 
oculaires,  permettant  meme  une  bonne  vision,  qui  ont  donne  lieu 
a  des  iridocyclites  violentes  apres  dix  huit  mois  ou  deux  ans. 

Une  seule  exception  peut  etre  admise  pour  les  corps  Strangers  intra- 
cristalliniens  qu'il  est  preferable  ou  d'abandonner  ou  d'extraire  avec 
la  totalite  de  la  cataracte. 

Malgre  tout,  nous  avons  conserve  I'impression  que  les  corps 
etrangers  intra-oculaires,  dus  a  des  blessures  de  guerre,  entrainent 
tou jours  un  pronostic  beaucoup  plus  grave  que  ceux  provenant  de 
traumatismes  industriels.  Ceci  se  congoit  facilement. 

2.  Si  tout  espoir  de  conserver  tout  ou  partie  de  la  fonction  visuelle 
doit  etre  abandonne,  on  devra  pratiquer  Pablation  du  segment  an- 
terieur,  1'evisceration  ou  meme  Tenucleation  s'il  ne  reste  plus  que 
des  debris  oculaires.     Operant  d'une  fagon  precoce,  cette  derniere 
sera  plus  rarement  employee,  ce  qui  est  toujours  preferable  au  point 
de  vue  prothe"tique.     Mais  le  blesse  sera  e*troitement  surveille"  les 
jours  suivants,  en  se  souvenant  que  de  violentes  douleurs  sont  le 
meilleur  signe  d'une  reaction  inflammatoire  et  qu'il  ne  faudra  pas 
he*siter  a  faire  une  enucleation  secondaire  seule  preventive  de  1'oph- 
talmie  sympathique. 

3.  Ces  operations  devront  etre  complete"es  par  le  manteau  conjoncti- 
val  qui  pour  etre  efficace  devra  etre  ample  et  bien  cousu.     La  con- 


Enseignements  de  la  Guerre  en  Chirurgie  Oculaire  47 

jonctive  largement  liberee  devra  e*tre  reunie  avec  le  plus  grand  soin 
d'un  bout  a  1'autre  au  moyen  de  sutures  separe'es  en  U. 

4.  On  terminera  par  la  refection  complete  et  methodique  des 
paupieres,  meme  les  plus  contuses,  en  evitant  les  larges  resections,  en 
regularisant  les  bords  des  plus  petits  lambeaux,.particulierement  au 
niveau  de  la  fente  palpebrale,  en  faisant  meme  des  autoplasties  par 
glissement  ou  par  renversement  du  lambeau,  avec  pedicule,  si  la  perte 
de  substance  est  trop  considerable. 

IV.  Toutes  les  blessures  orbitaires  devront  etre  abordees  par  de 
larges  orbitotomies,  meme  si  le  traumatisme  a  directement  interesse 
le  globe;  apres  avoir  traite  les  plaies  de  1'oeil  comme  il  est  dit  plus 
haut,  on  fera  une  longue  incision  courbe  suivant  le  rebord  osseux. 
Elle  permettra  d'aller  a  la  recherche  des  corps  etrangers,  des  fragments 
osseux  ou  des  volumineux  hematomes.  L'orbitotomie  suivant  les 
bords  inferieur  et  externe  donne  la  plus  large  voie  d'acces  meme  sans 
resection  de  la  paroi  externe  a  la  Kronlein.  Mais  le  lieu  de  1'incision 
sera  souvent  commande  par  les  lesions  osseuses.  L'orbitotomie  sera 
done  superieure  pour  1'exploration  de  la  voute  orbitaire,  supero- 
interne  pour  les  sinus  frontaux  et  meme  franchement  interne  pour 
aborder  les  sinus  ethmoidaux.  Elle  nous  a  permis  a  plusieurs  re- 
prises de  rechercher  des  fracas  osseux  et  des  corps  etrangers  situes 
profondement  dans  la  partie  interne  de  1'orbite  et  dans  le  massif 
ethmoidal.  Apres  le  nettoyage  soigne  des  parties  profondes, 
1'incision  de  1'orbitotomie  suturee  se  reunira  toujours  a  premiere 
intention. 


Telles  sont  les  considerations  qu'il  m'a  paru  de  quelque  interet  de 
presenter  au  Congres  International. 

Si  nous  nous  reportons  a  la  chirurgie  orbito-oculaire  de  1914,  et 
surtout  aux  methodes  employees  au  debut  de  la  guerre,  il  nous  semble 
juste  de  dire  qu'un  progres  considerable  a  ete  realise.  Ces  resultats 
favorables  sont  dus  surtout  au  traitement  chirurgical  aussi  precoce 
que  possible,  aide  par  1'anesthesie  locale  a  la  novocame,  avec  recherche 
des  lesions  profondes  de  1'orbite  et  sutures  primitives  de  plaies 
cutanees  et  conjonctivales.  Depuis  la  guerre  nous  avons  continue*  a 
appliquer  rigoureusement  ces  methodes  dans  les  traumatismes  acci- 
dentels,  elles  nous  ont  donne  la  plus  entiere  satisfaction. 


48  F.  DE  LAPERSONNE 

DISCUSSION 

DR.  FREDERICK  T.  TOOKE  (Montreal,  Canada) :  It  affords  me  pleasure,  as 
an  old  student  of  Professor  de  Lapersonne,  to  offer  him  my  felicitations  on  his 
beautiful  presentation.  It  would  not  be  fitting  on  my  part  to  raise  any  points 
in  discussion ;  but  those  of  us  who  perhaps  have  had  a  little  experience  in  war 
surgery,  and  those  who  have  been  able  to  follow  him  in  his  own  language, 
notice  Professor  de  Lapersonne's  directness  of  thought,  the  same  as  in  former 
years,  and  his  beauty  and  simplicity  of  manner. 

Without  bringing  up  any  point  of  discussion  I  can  simply  assure  Professor 
de  Lapersonne  and  those  who  have  heard  him  that  "old  friends  are  dearest  and 
old  tunes  are  sweetest."  Many  of  his  observations  may  perhaps  be  well 
known,  and  the  application  of  some  of  the  points  he  has  brought  out,  more 
particularly  in  civilian  life,  may  be  interpreted  by  the  latter  part  of  the  quota- 
tion. I  am  sure  I  can  assure  Professor  de  Lapersonne  on  your  behalf,  as  I  do 
most  heartily  on  my  own,  that  from  now  on  the  first  part  of  the  quotation  as 
to  old  friends  will  apply  very  directly. 

DR.  GEORGE  S.  DERBY  (Boston,  Mass.) :  I  feel  it  a  privilege  to  testify  to 
the  great  help  which  we  medical  men  of  the  army  serving  in  France  obtained 
from  our  French  colleagues.  I  had  the  opportunity  to  attend  the  meetings 
of  the  Socie'te'  Franchise  d'Ophtalmologie,  and  to  visit  the  clinics  of  Prof, 
de  Lapersonne,  Dr.  Morax,  and  Prof.  Lagrange,  and  from  each  place  I  went 
away  with  information  which  certainly  was  of  great  benefit  to  me.  Among 
the  important  observations  of  our  French  colleagues  were  the  value  of 
thorough  exploration  and  cleaning  of  wounds;  the  employment  of  sutures 
early  as  an  aid  to  better  cosmetic  results;  the  benefits  to  be  obtained  from 
collaboration  with  those  engaged  in  other  branches  of  surgical  work;  the 
effects  and  treatment  of  gas  cases,  especially  mustard  gas;  and  the  effect  of 
contusions,  either  as  a  result  of  direct  injury  to  the  eye  or  as  secondary  affec- 
tions— the  contusions  which  have  been  so  beautifully  described  and  pictured 
by  Prof.  Lagrange. 

Our  experience  with  sympathetic  disease  was  the  same  as  others,  and  I 
think  much  was  due  to  their  teaching  in  regard  to  early  exploration  and  treat- 
ment. It  seems  remarkable  that  the  results  in  regard  to  sympathetic  disease 
should  have  been  so  good,  because  in  many  cases  the  eyes  were  actually  in 
pieces  and  it  was  with  the  greatest  difficulty  that  the  torn  remnants  were 
removed  from  the  orbit. 

The  value  of  local  anesthesia,  to  which  Prof,  de  Lapersonne  devotes  so 
much  attention,  and  the  early  search  for  foreign  bodies  within  the  eye  and 
their  immediate  removal  if  the  sight  of  the  eye  was  to  be  saved,  in  any  con- 
siderable number  of  cases,  were  shown  in  the  work  of  his  clinic.  We  were 
also  impressed  with  the  results  secured  by  Prof,  de  Lapersonne  and  his  col- 
leagues in  plastic  operations,  and  the  wonderful  prosthetic  appliances  devised 
by  them  and  which  did  so  much  to  restore  the  good  appearance  of  those  who 
were  mutilated  in  the  war. 

DR.  ALLEN  GREENWOOD  (Boston,  Mass.) :  I  wish  to  draw  attention  to  the 
fact  that  there  probably  may  have  been  some  difference  between  the  French 


Enseignements  de  la  Guerre  en  Chirurgie  Oculaire  49 

soldiers  and  our  own,  particularly  in  regard  to  infection  with  the  Bacillus 
Welchii.  I  have  personal  records  at  this  time  of  three  cases  of  gas  gangrene 
of  the  orbit.  From  the  three  cases  the  Bacillus  Welchii  was  obtained  in 
nearly  pure  culture,  giving  a  positive  diagnosis  of  gas  gangrene  of  the  orbit. 
One  of  these  men  died  from  infection,  but  the  other  two  recovered  after  free 
drainage  of  the  orbit. 

PROFESSOR  G.  F.  ROCHAT  (Groningen,  Holland) :  C'est  vraiment  remar- 
quable  que  sur  tant  de  milliers  de  Hesse's  de  1'oeil,  il  se  trouvent  si  peu  de  cas 
d'ophtalmie-sympathique.  D'abord  on  a  meme  cru  que  les  cas  d'ophtalmie- 
sympathique  etaient  d'une  rarete  exceptionnelle  et  il  se  trouvent  dans  la 
literature  frangaise  quelques  communications  dans  lesquelles  les  auteurs 
doutent  que  1'ophtalmie-sympathique  se  soit  jamais  montre'e.  Mais,  comme 
nous  venons  d'apprendre,  le  Docteur  Morax  a  public  une  statistique  sur  39 
cas.  Ce  qui  est  encore  tres  peu.  Ce  re"sultat  heureux  est  sans  doute  attri- 
buable  a  1'habilite"  de  nos  confreres  frangais  et  aux  soins  judicieux  que  les 
malades  recurent.  Mais  il  me  semble  qu'en  dehors  d'une  signification  pure- 
ment  pratique,  ces  re"sultats  ont  une  importance  au  point  de  vue  de  la  thiorie, 
car  ils  parlent  fortement  en  faveur  de  la  theorie  que  1'ophtalmie-sympathique 
soit  une  infection  et  non  pas  une  reaction  anaphylactique  due  au  pigment 
oculaire.  Si  1'ophtalmie-sympathique  fut  due  au  pigment  oculaire,  on  1'aurait 
surement  rencontre1  tres  souvent  dans  tant  de  milliers  de  blessures  perforantes 
avec  destruction  de  1'epithelius  pigmente.  Et,  d'autre  part,  1'observation 
qu'a  fait  M.  de  Lapersonne,  que  1'ophtalmie-sympathique  s'est  surtout 
montre1  dans  les  cas  de  plaie  pe'ne'trante,  sans  vastes  eclatements,  mais  avec  de 
petits  corps  Strangers  intraoculaires,  ce  que  s'explique  facilement  en  admet- 
tant  une  infection,  mais  difficilement  par  la  theorie  anaphylactique. 

DR.  E.  E.  BLAAUW  (Buffalo,  N.  Y.) :  Je  viens  justement  d'arriver  et  n'ay 
pas  eu  le  temps  de  me  pr^parer.  Veuillez  Ms.  de  Lapersonne  me  prendre 
comme  je  suis.  Permettez-moi  de  nous  congratuler  que  vous  nous  avez 
donne"  la  possibility  de  renouveler  la  connaissance  que  nous  avons  fait  au 
prece'dant  congres  de  Naples. 

Comme  marque  de  mon  appreciation  et  de  mon  inte"ret  pour  1'ophtal- 
mologie  francaise,  je  vous  demande  de  me  donner  votre  opinion  sur  cette 
question:  "Quand  on  voit,  specialement  apres  un  traumatisme  que  des 
vaisseaux  viennent  invader  le  parenchyme  de  la  cornee  et  passent  aussi  pres 
de  la  Descemet,  est-ce  que  vous  conseillez  I'e'nucle'ation  immediate?" 

PROFESSOR  DE  LAPERSONNE  (closing) :  Je  remercie  bien  mes  collegues,  qui 
ont  fait  des  observations  au  sujet  de  ma  communication.  Ils  ont  approuve 
d'une  fagon  g6n6rale,  ce  que  nous  avons  observe1  en  France.  La  question 
d'ophtalmie-sympathique  n'a  pas  ete"  discute"e  au  point  de  vue  the"orique,  mais 
il  est  eVident  qu'elle  est  d'origine  infectieuse  plutot  qu'anaphylactique.  Ceci 
est  plutot  de  la  theorie. 

En  ce  qui  concerne  la  question  de  l'e"nucleation  qui  doit  etre  faite  dans  les 
blessures  re'centes,  je  crois,  en  effet,  que  toute  infection  ayant  pour  point  de 
depart,  1'iris,  le  corps  ciliaire  avec  vascularisation  de  la  corne"e,  est  un  signe 
tres  important,  et  il  est  ne"cessaire  de  faire  1'enucle'ation  le  plus  tot  possible. 
4 


DETACHMENT  OF  THE  VITREOUS 

SIR  WILLIAM  LISTER 

London,  England 

I  will  begin  my  paper  by  briefly  summarizing  the  information  I 
have  been  able  to  gather  with  regard  to  the  development  and  structure 
of  the  vitreous,  and  will  then  describe  some  of  the  changes  which  take 
place  in  it  following  hemorrhage  or  inflammatory  infiltration,  which 
are  often  associated  with  its  contraction  and  detachment,  and  later 
proceed  to  my  chief  theme,  namely,  "Detachment  of  the  Vitreous," 
and  consider  its  frequency,  its  causation,  its  effects,  and  finally  its  in- 
fluence on  certain  pathologic  changes  in  the  posterior  part  of  the  eye. 

DEVELOPMENT 

From  the  beautiful  work  of  Mawas  and  Magitot  it  seems  possible 
that  the  old  view  we  were  taught,  that  the  vitreous  was  derived  from 
the  mesoblast,  which  entered  the  secondary  optic  vesicle  through  the 
choroidal  cleft,  is  incorrect  and  that  the  vitreous  is  mainly  epiblastic 
in  origin  and  that  its  development  takes  place  in  three  stages : 

1.  There  is  a  primordial  vitreous,  formed  almost  entirely  from  the 
retinal  epithelial  cells,  especially  from  those  of  the  pars  ciliaris,  and 
to  a  very  slight  extent  from  the  cells  of  the  lens. 

2.  This  primordial  vitreous  is  temporarily  pushed  aside  by  the  in- 
vasion of  the  mesoblast,  both  that  part  which  comes  in  through  the 
choroidal  cleft  and  that  which  enters  the  secondary  optic  vesicle 
anteriorly  with  the  inclusion  of  the  lens.     This  mesoblast  forms  what 
they  call  the  transitory  vitreous,  viz.,  the  vascular  tissue  which 
temporarily  occupies  the  greater  part  of  the  so-called   "vitreous 
chamber,"  and  ensheathes  the  lens,  but  soon  disappears,  remaining 
only  as  the  walls  of  the  hyaloid  canal. 

3.  Corresponding  with  the  disappearance  of  the  vascular  transitory 
vitreous,  the  primordial  vitreous  tissue  undergoes  great  development 
and  becomes  the  main  vitreous  body,  or  definitive  vitreous. 

Their  view  is,  then,  that  the  main  vitreous  body  is  epiblastic  and 

50 


Detachment  of  the  Vitreous  51 

not  mesoblastic  in  origin,  and  is  derived  chiefly  from  the  retinal  cells 
of  the  pars  ciliaris. 

In  this  definitive  vitreous  fibers  are  found  which  are  continuous 
with  and  closely  united  to  the  cells  of  the  pars  ciliaris.  The  firm 
adherence  of  the  vitreous  to  the  pars  ciliaris  found  in  post-natal  life 
is  thus  associated  with  its  origin;  while  to  the  rest  of  the  retina  the 
vitreous  is  merely  applied,  or  if  attached,  only  very  slightly.  One 
would  expect,  therefore,  that  on  contraction  detachment  would  take 
place  at  the  posterior  region  from  the  retina  proper,  with  a  heaping-up 
of  the  vitreous  into  a  mass  situated  behind  the  lens  and  the  pars 
ciliaris. 

STRUCTURE  OF  VITREOUS  BODY 

The  vitreous  in  its  fresh  state  is  a  pellucid,  soft,  gelatinous  mass, 
apparently  structureless  except  for  the  so-called  "corpuscles"  of  the 
vitreous,  of  which  some  show  ameboid  movement  and  contain  large 
vacuoles.  That  the  rest  of  the  vitreous  is  not  entirely  homogeneous 
is  shown  by  the  fact  that,  when  thrown  on  a  filter,  a  small  portion 
always  remains,  although  by  far  the  larger  part  drains  away  and  may 
be  collected  as  clear  watery  fluid. 

When  hardened  and  stained,  a  certain  amount  of  structure  can  be 
made  out.  Definite  fibers,  already  referred  to,  can  be  seen  chiefly  in 
the  external  part  of  the  vitreous,  and  especially  in  the  region  opposite 
the  ciliary  body,  to  which  the  fibers  are  firmly  attached.  These  fibers 
in  the  ciliary  region  are  in  series  with  the  fibers  of  the  suspensory  liga- 
ment, which  indeed  are  considered  by  many  to  be  merely  a  highly 
developed  group. 

"HYALOID  MEMBRANE." — Investing  the  whole  of  the  vitreous,  a 
"hyaloid  membrane"  has  been  described  as  a  specialized,  thin,  glassy 
layer.  Schafer  describes  the  hyaloid  as  consisting  of  two  layers  in 
the  ciliary  region — an  inner  one,  which  continues  forward,  the  in- 
vesting coat  of  the  vitreous,  and  an  outer  fibrous  layer,  which  is 
closely  adherent  to  the  pars  ciliaris,  and  anteriorly  passes  forward  to 
fuse  with  the  capsule  of  the  lens  and  forms  the  suspensory  ligament. 
Of  the  existence  of  the  suspensory  ligament  there  is,  of  course,  no 
question,  but  certain  observers  have  doubted  the  existence  of  these 
other  vitreous  structures. 

When  fixed  in  chromic  acid,  more  or  less  distinct  lamellation  of  the 
vitreous  can  be  seen,  especially  in  the  part  next  the  retina,  which,  in 
the  human  eye,  is  of  a  firmer  consistence  than  the  central  portion.  In 


52  WILLIAM  LISTER 

addition  to  this  indication  of  concentric  lamellation  a  radial  marking 
has  also  been  observed  in  sections  made  transversely  to  the  axis  of  the 
eyeball  in  similarly  hardened  specimens  (Hanover). 

Some  consider  that  the  indications  of  concentric  lamellation  and 
radial  striation  and  even  the  hyaloid  membrane  are  artefacts  due  to 
hardening  reagents,  but  I  think  when  certain  pathologic  states  of  the 
vitreous  are  examined,  they  afford  strong  supporting  evidence  of 
some  such  structural  formation. 

We  may  look  upon  hemorrhage  or  infiltration  into  the  vitreous  as 
most  useful  staining  reagents  of  the  vitreous  in  situ  and  in  vita. 

Now  it  is  well  known  that  the  vitreous  may  undergo  various  de- 
generations; it  may  liquefy  and  lose  its  gelatinous  character,  and 
when  liquefied,  it  may  either  remain  clear — as  is  so  often  seen  in  cases 
of  high  myopia — or  it  may  become  impregnated  with  products  of 
degeneration,  such  as  cholesterin,  as  in  synchysis  scintillans.  It 
would  be  expected  that  in  a  vitreous  which  had  become  liquefied  any 
structural  characteristics,  if  they  existed,  would  be  lost,  and  if  subse- 
quently it  were  infiltrated  with  round  cells  or  blood,  a  comparatively 
even  or  general  infiltration  would  take  place;  whereas  if  infiltration 
takes  place  in  a  previously  healthy  vitreous,  some  evidence  of  struc- 
ture, if  such  existed,  might  be  expected  .to  be  seen  in  the  first  stages 
before  the  whole  vitreous  became  purulent;  it  is  this  evidence  I  hope 
to  demonstrate.  It  is  probably  the  anatomic  structure  of  the  vitreous 
which  is  the  chief  deciding  factor  that  brings  about  the  varied  appear- 
ances of  the  vitreous  seen  on  pathologic  examination  after  effusion 
of  blood  or  round  cells  into  it. 

In  septic  infection  of  the  vitreous  a  great  variety  in  the  distribu- 
tion of  the  round  cells  is  seen — 

(a)  In  some,  the  vitreous  is  evenly  cloudy  or  evenly  purulent.    This 
may  be  due  to  the  preexisting  liquefied  state  of  the  vitreous,  or  to  the 
suppuration  having  been  so  prolonged  that  any  early  uneven  infiltra- 
tion had  become  lost,  or  to  a  special  infection  causing  liquefaction 
of  the  vitreous  pari  passu  with  'the  infiltration. 

(b)  In  others  the  infiltration  is  far  from  homogeneous,  thus : 

1.  Stilling's  canal  may  be  seen  demarcated  in  pus. 

2.  In  other  cases  we  see  pus  extending  backward  from  the  ciliary 

region,  after  anterior  infection,  in  streaks  or  Medusa-like 
locks,  while  in  others  there  is  very  definite  and  beautiful 
lamination  of  the  layers  of  pus. 
Such  irregular  distribution  of  the  round-celled  infiltration  must  be 


Detachment  of  the  Vitreous  53 

determined  by  some  cause,  and  could  be  determined  by  lamellation  of 
the  vitreous  or  some  remains  of  it.  Thus  cases  with  streaks  or  layers 
of  pus  in  the  vitreous  appear  to  give  strong  support  to  the  view  that 
the  vitreous  body  is  not  originally  structureless,  but  lamellated. 

Though  for  years  a  specialized  investing  coat  of  the  vitreous  or 
hyaloid  membrane  has  been  described,  others,  Mawas  and  Magitot, 
for  instance,  state  that  no  such  structure  exists. 

Pathologic  conditions  again  throw  light  on  the  matter.  When 
looking  at  specimens  macroscopically,  with  infiltration  of  the  vitreous 
associated  with  some  degree  of  detachment,  though  in  some  the  pos- 
terior boundary  of  the  vitreous  is  shaggy  and  there  is  no  definite  edge, 
in  others  the  vitreous  has  a  perfectly  defined  margin.  Such  definition 
of  the  vitreous  must  have  a  determining  cause.  It  seems  impossible 
to  avoid  the  view  that  there  is  some  specialized  layer  limiting  the 
vitreous  which,  provided  it  has  not  been  previously  degenerated,  is 
capable  of  checking,  to  some  extent,  the  progress  of  invading  leuko- 
cytes; but  if  the  vitreous  were  degenerated  and  liquefied,  such  limit- 
ing membrane  would  break  up  and  disappear,  and  when  infiltration 
takes  place,  no  definite  demarcation  of  the  vitreous  is  visible,  but  its 
limits  are  shaggy. 

Another  group  of  cases  may  throw  some  light  on  the  structure  of  the 
vitreous,  though  this  is  doubtful,  but  they  are  interesting  and  afford 
scope  for  speculation. 

When  a  foreign  body  has  passed  through  the  vitreous,  it  is  not 
uncommon  to  find  straight  thin  planes  of  fibrous  tissue  traversing  the 
vitreous  in  one  or  more  places.  These  planes  are  very  surprising; 
doubtless  they  are  the  result  of  hemorrhage,  but  one  naturally  wonders 
why  the  hemorrhage  should  be  limited  to  a  definite  plane.  One 
would  expect  to  find  a  tuft  of  hemorrhage  rather  than  a  defined  thin 
sheet.  I  think  two  suggestions  can  be  put  forward  in  explanation: 

(a)  Either  that  the  explosive  force  of  the  penetration  split  the 
vitreous  just  as  a  jelly  (containing  insufficient  gelatin  for  artistic 
cooking)  splits  on  a  plate,  or  as  a  glacier,  which  we  are  told  follows  the 
same  laws  as  semisolids,  splits  into  seracs  as  it  passes  over  a  projecting 
portion  of  its  underlying  bed,  or — 

(b)  That  some  radial  structure  of  the  vitreous  has  determined  this 
peculiar  distribution  of  the  effused  blood. 

Whatever  may  be  the  exact  explanation  of  the  latter  group,  the  ex- 
amination of  the  pathologic  specimens  shown  tends  to  confirm  the 


54  WILLIAM  LISTER 

view  that  the  vitreous  has  structure  of  a  lamellated  character — and 
also  that  it  possesses  a  definite  and  specialized  limiting  membrane. 

DETACHMENT  OF  THE  VITREOUS 

Detachment  of  the  vitreous  is  dismissed  by  Fuchs  in  his  text-book 
very  summarily  as  being  much  less  common  than  was  thought  to  be 
the  case.  He  writes:  "...  Such  detachment  is  much  more 
rare  than  was  formerly  supposed,  when  observers  were  misled  by 
the  presence  of  artefacts  produced  by  the  hardening  of  the  speci- 
mens," inferring  that  in  most  instances,  when  it  is  found  on  pathologic 
examination,  it  is  due  to  the  fixing  reagent.  That  detachments  are 
certainly  not  all  due  to  fixing  reagents  is  proved : 

1.  By  the  fact  that  in  eyes  fixed  in  formalin,  for  instance,  detach- 
ment of  the  vitreous  is  not  present  in  a  large  number  of  specimens. 

In  some  it  is  present;  in  others,  the  vitreous,  clear  or  infiltrated, 
may  fill  the  whole  or  practically  the  whole  of  the  space  normally 
allotted  to  it.  If  the  formalin  caused  contraction,  detachment 
would  surely  be  present  in  every  case  examined,  except  where  there 
was  some  morbid  attachment  of  the  vitreous  to  the  retina. 

2.  By  the  presence  of  changes,  shortly  to  be  described,  which,  from 
their  complicated  structure,  could  not  possibly  be  postmortem  arte- 
facts, especially  those  found  in  the  clear  retrovitreous  space  un- 
attached in  any  way  to  the  vitreous  body. 

While  it  is  well  known  that  certain  reagents,  such  as  alcohol, 
cause  extreme  contraction,  there  seems  no  reason  for  thinking  that 
formalin  causes  any  alteration  in  the  size  of  the  vitreous.  Detach- 
ment of  the  vitreous  is  without  doubt  commonly  found  in  eyes  fixed 
in  formalin  and  examined  pathologically,  and  there  seems  to  be  clear 
evidence  that  such  separation  of  the  vitreous  from  the  retina  proper 
has  taken  place  during  life,  and  is  due  either  to  actual  contraction  of 
the  vitreous  body  or  to  its  liquefaction,  resulting,  in  either  case,  in 
the  occurrence  of  a  zone  of  nearly  clear  fluid  between  the  retina  and 
the  vitreous,  such  as  has  been  for  long  described  in  myopia. 

In  cases  of  the  more  chronic  infection  of  the  eye,  all  stages  of  con- 
traction are  met  with.  In  the  early  and  slighter  cases,  what  little 
separation  from  the  retina  exists  is  only  at  the  posterior  pole,  the 
vitreous  still  remaining  attached  to  the  optic  disc.  This  is  the  last 
spot  for  detachment  to  occur  in  this  posterior  region,  and  it  is  the 
site  at  which  greater  adherence  would  be  expected,  since  it  is  here 
that  the  hyaloid  vessels  passed  from  the  disc  into  "Stilling's  canal." 


Detachment  of  the  Vitreous 


55 


Fig.  1. — Embryonic  vitreous,  showing 
meshwork  of  fibers  and  nodes. 


Fig.  2. — Punctate  deposits  on  retina 
seen  on  flat,  demonstrating  that  they 
have  no  special  relation  to  the  retinal 
vessels. 


Fig.  3. — Pus  extending  backward  from 
ciliary  region. 


Fig.  4. — Detachment  of  vitreous  with 
sharply  defined  margins. 


56  WILLIAM  LISTER 

In  the  later  stages  of  chronic  inflammation  the  vitreous  becomes  con- 
tracted up  into  a  firm  mass  behind  the  lens. 

Between  these  two  extreme  forms — the  slighter  and  the  greater — all 
intermediate  varieties  are  found. 

An  interesting  and  important  variety  is  met  with  when  the  vitreous 
becomes  adherent  to  the  retina  at  one  or  more  spots.  Such  adhesion 
may  be  the  result  either  of  inflammation  in  the  retina  due  to  a  foreign 
body  striking  it  within,  a  perforation  of  the  ocular  coats  from  with- 
out, or  from  some  other  cause,  such  as  a  hemorrhage  from  the  retina 
bursting  into  the  vitreous  or  a  patch  of  retinochoroiditis.  When 
contraction  of  the  vitreous  subsequently  takes  place,  it  remains,  as 
it  were,  "pegged  out"  at  certain  parts,  as  we  shall  see  later. 

Now,  what  the  factor  is,  apart  from  traumatic  loss  of  vitreous, 
which  causes  the  diminution  in  its  bulk  and  consequent  separation 
or  detachment  from  the  retina  to  take  place,  it  is  difficult  to  say.  We 
know  that  scar  tissue  tends  to  contract,  and  it  is,  therefore,  to  be  ex- 
pected that  when  fibrous  tissue  has  replaced  the  hemorrhage  or 
inflammatory  exudate,  contraction  of  such  a  loosely  attached  body  as 
the  vitreous  would  ensue,  but  is  it  known  why  scar  tissue  contracts, 
apart  from  consolidation  and  loss  of  fluid?  It  is  less  easy  to  under- 
stand why  in  the  early  stages  of  suppuration  of  the  less  acute  types 
contraction  is  so  common.  Still  more  is  it  difficult  to  see  why,  when 
there  has  been  no  hemorrhage  or  infiltration,  the  vitreous  should 
shrink. 

I  now  pass  on  to  show  how  detachment  of  the  vitreous  determines 
certain  pathologic  conditions. 

I.  SUPPURATIVE  INFLAMMATIONS. — (i)  When  the  head  of  the  optic 
nerve  has  been  irritated  by  toxins  or  organisms  brought  to  it  by  the 
lymph-stream  and  pus  pours  out  from  the  disc,  we  find  quite  different 
appearances  in  specimens  where  the  vitreous  is  in  situ  from  those 
where  the  vitreous  has  been  detached.  Thus  in  the  former  we  have  seen 
"Stilling's  canal"  injected  with  infiltrate,  or  others  where  a  fountain 
of  exudate  jets  out  into  the  vitreous.  Whereas  in  similar  cases  of 
irritation  of  the  optic  disc  when  the  vitreous  has  become  detached  a 
beautiful,  fan-like  growth  of  pus  may  extrude  out  from  the  papilla 
into  the  zone  of  clear  fluid  behind  the  contracted  vitreous. 

(ii)  When  the  so-called  "abscess  of  the  vitreous"  is  formed  around 
a  retained  foreign  body  lying  somewhere  in  the  retrolental  area,  the 
shrunken  and  infiltrated  vitreous  closely  enwraps  the  bag  of  pus, 
while  the  rest  of  the  vitreous  chamber  is  filled  with  clear  fluid. 


Detachment  of  the  Vitreous  57 

(iii)  In  other  cases,  as  we  have  already  seen,  when  the  vitreous  be- 
comes attached  to  the  retina,  we  find  it  contracted  forward  but 
"pegged  out"  to  the  retina  at  certain  spots. 

(iv)  Again,  in  other  cases  of  chronic  infection  with  detachment  of  the 
vitreous,  punctate  deposits  on  the  retina  may  occur — as  I  described  in  a 
paper  at  the  last  Congress  of  the  Ophthalmological  Society  of  the 
United  Kingdom. 

II.  HEMORRHAGE. — If  a  hemorrhage  takes  place  into  the  vitreous 
from  the  retina  or  choroid,  we  know,  from  Parsons'  work,  the  exact 
changes  that  occur.  Either  the  blood  elements  may  be  completely 
absorbed,  or  if  fibroblasts  enter  from  the  retina  or  choroid,  a  spindle 
or  a  fan  of  fibrous  tissue  may  be  formed,  such  as  one  sees  in  retinitis 
proliferans,  whether  of  the  "so-called"  idiopathic  or  of  the  traumatic 
variety. 

I  have  a  particularly  beautiful  specimen  of  a  small  hemorrhage 
which  burst  into  the  vitreous  from  the  retina  as  a  result  of  concussion, 
following  which  the  vitreous  began  to  detach,  and  a  pointed  tag  of 
vitreous,  with  a  hemorrhagic  tip,  was  left  attached  to  the  retina.  As 
the  vitreous  contracted  the  pointed  tag  dragged  on  the  retina  and 
caused  this  also  to  detach.  That  the  retinal  detachment  was  present 
during  life  and  not  the  result  of  the  fixative  is  clearly  demonstrated 
by  the  fact  that  in  the  post-retinal  space  there  is  an  albuminous 
coagulum  which  must  have  been  there  before  excision. 

It  seems  to  me  one  ought  to  lay  great  stress  on  these  tags  of  fibrous  tissue 
in  the  vitreous  which  are  attached  to  the  retina,  for  I  believe  they  give 
rise  to  at  least  four  separate  and  important  phenomena.  As  is  well 
known,  by  their  traction  they  may  cause  folding  of  the  retina,  de- 
tachment of  the  retina,  but  I  believe  they  may  also  give  rise  to  holes 
in  the  retina  and  to  the  flashes  which  occur  on  movement  in  highly 
myopic  eyes. 

Now,  it  is  well  known  that  hemorrhages,  especially  in  myopic  eyes, 
are  all  too  common,  and,  in  the  specimens  shown,  it  is  seen  that 
fibrous  tags  may  develop  as  a  result  of  hemorrhage.  When  once 
they  are  formed,  then,  by  their  traction,  not  only  a  detachment,  but 
I  think  one  variety  of  hole  in  the  retina,  may  result.  There  are  at 
least  five  varieties  of  holes  in  the  retina : 

(i)  The  nearly  circular  holes  which  occur  at  the  macula  as  the  result 
of  a  blow,  from  a  comparatively  slowly  moving,  non-penetrating 
missile,  on  the  front  of  the  eye. 

(ii)  Other  circular  lacunae  at  the  macula,  associated  with  retino- 


58 


WILLIAM  LISTER 


Fig.  5. — Even  infiltration  of  vitreous 
with  commencing  detachment.  Vitre- 
ous remains  attached  to  optic  disc. 


Fig.  6. — Through  and  through 
wound.  Vitreous  attached  to  retina  at 
site  of  exit. 


Fig.  7. — Suppuration  showing  Still- 
ing's  canal  infiltrated  with  pus  and 
other  streaks  of  pus  in  the  vitreous. 


Fig.  8. — Fibrous  fans  in  the  vitreous 
following  hemorrhage,  formed  before 
detachment  of  the  vitreous  has  taken 
place. 


Detachment  of  the  Vitreous  59 

choroiditis,  exactly  resembling  those  following  a  blow,  which  are  very 
probably  due  to  bursting  of  cysts  at  the  macula. 

In  neither  of  these  two  groups  is  there,  as  a  rule,  much  if  any  de- 
tachment. 

(iii)  Then  there  are  peripheral  holes  due  to  traumata — with  or 
without  detachment. 

(iv)  There  are  also  holes  associated  with  retinochoroiditis  (else- 
where than  at  the  macula)  which  has  caused  adhesion  of  the  retina 
to  the  choroid.  Subsequent  detachment  of  the  retina  results  in  a 
rent  in  this  membrane  (Elschnig's  theory).  With  this  condition  a 
hole  may  occur  in  two  different  ways — according  to  whether  the 
retina  is  pushed  in  by  fluid  in  the  post-retinal  space  or  drawn  in  by 
an  adherent  and  contracting  vitreous. 

(a)  When  fluid  collects  between  the  retina  and  pigment  epithelium 

and  pushes  the  retina  in,  the  retina  may  be  torn  at  a  point 
of  attachment.  Such  a  cause  can  produce  only  a  single 
hole,  for  directly  a  breach  takes  place,  the  pressure  on  the 
two  sides  of  the  retina  would  be  equalized. 

(b)  When,  however,  the  vitreous  is  attached  to  the  retina  and 

drags  it  inward,  then  any  number  of  holes  may  occur  cor- 
responding with  the  number  of  points  of  adhesion  of  the 
retina  to  the  choroid. 

(v)  Horseshoe-shaped  Rents. — It  is  these  "horseshoe"  rents  which, 
I  believe,  are  due  to  traction  of  vitreous  tags,  for  in  these  we  often 
notice  that  the  central  portion  of  the  horseshoe  is  pulled  inward  by 
a  tag  of  fibrous  tissue.  It  would  seem  extremely  probable  that 
traction  of  such  fibrous  tissue  attached  at  one  end  to  the  retina,  and 
at  the  other  to  a  contracting  vitreous,  would  be  sufficient  to  cause  a 
rent. 

Such  a  pulling  in  of  the  center  of  the  horseshoe  probably  many  of 
us  have  seen  both  clinically  and  pathologically. 

Though  it  would  seem  possible  that  a  steady  pull  might  be  sufficient 
to  cause  a  rent,  yet  probably  tearing  could  more  easily  be  produced 
on  sudden  rotation  of  the  eye.  Thus,  when  a  wineglass  containing 
liquid  is  rotated,  the  glass  turns  before  the  liquid;  similarly,  in  an 
eye  with  contracted  and  detached  or  partially  liquefied  vitreous, 
where  a  large  part  of  the  vitreous  cavity  is  filled  with  limpid  fluid, 
sudden  rotation  of  the  eye  will  cause  the  coats  of  the  globe  to  move 
sooner  than  the  fluid  contents.  If  there  is  a  fibrous  tag  attached, 


60  WILLIAM  LISTER 

on  the  one  hand,  to  the  retina,  and,  on  the  other,  to  the  contracted 
vitreous,  though  in  a  state  of  rest  it  might  cause  little  or  no  tension  on 
the  retina,  yet  on  rotation  a  sudden  tweak  might  be  produced  by  it 
on  the  retina  at  the  point  of  attachment  sufficient  to  bring  about  a 
tear,  and  especially  if  the  retina  is  weakened  by  cystic  degeneration. 
Slighter  pulls  by  such  tags  might  be  sufficiently  forcible  to  stimulate 
the  retina  and  cause  flashes  on  movement  of  the  eye. 

If,  then,  a  vitreous  hemorrhage  may  be  followed  by  a  fibrous  tag, 
which  in  time  may  cause  detachment  of  the  retina,  we  have  an  obvi- 
ous practical  indication  to  desist  from  all  avoidable  punctures  of  the 
vascular  coats  of  the  eye,  and  thus  a  strong  reason  for  removing 
foreign  bodies  with  the  magnet  by  the  "anterior  route,"  through  the 
avascular  cornea,  rather  than  by  the  "posterior  route,"  through  a 
new  incision  in  the  vascular  sclerotic  choroid  and  retina,  from  any  of 
which  structures  a  hemorrhage  may  pass  into  the  vitreous. 

If  a  hemorrhage  from  the  disc  or  the  retina  occurs  after  the  vitreous 
has  become  detached,  quite  a  different  appearance  is  found  from  that 
when  the  vitreous  is  in  situ.  Just  as  we  have  seen  that  pus  may  ex- 
tend from  the  disc  in  fern-like  fronds  in  the  space  behind  the  vitreous, 
so  fibrous  tissue  fans  may  be  developed  in  this  space,  which  presumably 
are  the  result  of  a  previous  hemorrhage.  I  have  an  interesting 
specimen  of  a  case  of  glaucoma  with  a  shrunken  vitreous  in  which  a 
large  hemorrhage  from  the  disc  was  followed  by  a  mass  of  fibrous 
tissue  filling  up  the  cup  and  extending  into  the  vitreous  chamber. 

In  grossly  degenerated  eyes  with  retinochoroiditis  we  find  the  retina 
glued  down  to  the  choroid,  and  the  vitreous  contracted  right  up  be- 
hind the  lens.  If  fibrous  tissue  bands  occur  between  the  retina  and 
contracted  vitreous,  though  the  retina  cannot  detach,  these  connecting 
bands  may  be  drawn  out  into  very  delicate  strands.  They  may  be 
either  in  the  form  of  small  fans  or  of  branching  filaments.  Some  of 
these  are  partially  pigmented  and  occasionally  contain  blood-vessels. 

The  last  section  of  my  paper  deals  with  what  I  propose  to  call 
"HOLES  IN  THE  HYALOID." 

That  such  a  membrane  or  differentiation  of  the  outer  layers  of  the 
vitreous  exists  is,  to  my  mind,  proved,  as  already  stated,  by  the  fact 
that  though  in  some  cases  of  contraction  and  detachment  of  the 
vitreous  its  edge  is  quite  shaggy  and  uncertain,  in  others  it  is  quite 
clearly  defined.  Its  existence  is  supported  by  other  evidence,  both 
clinical  and  pathologic. 

1.  Thus  in  the   case  of  an   injury  from   a  stone  a  hemorrhage 


Detachment  of  the  Vitreous 


61 


Fig.  9. — Hole  in  hyaloid.     Opaque  ring  in  vitreous,  which  on  movement  of  eye 
appeared  in  three  definite  positions. 


Fig.  10. — Horseshoe  hole  in  retina.  Fig.    11. — a,    Detached    retina;     b, 

Tag  of  fibrous  tissue  attached  to  the  shrunken   vitreous;   c,   hole  to  which 

inturned  flap  of  retina,  as  seen  with  is  attached  shrunken  vitreous, 
ophthalmoscope. 


62  WILLIAM  LISTER 

occurred  at  the  macula  which  gave  rise  to  a  star  figure  of  fibrous 
tissue  from  which  radiated  out  multitudinous  delicate  rays  imme- 
diately over  the  retina.  These  were  much  too  fine  to  be  foldings 
of  the  retina,  such  as  one  sees  in  cases  of  retinal  edema,  etc.,  and  I 
have  no  doubt  they  were  due  to  foldings  of  the  hyaloid. 

2.  Again,  we  come  across  cases  clinically  in  which,  with  the  oph- 
thalmoscope, a  fine  membrane  is  seen  in  the  vitreous  chamber,  3  to  6 
D.  in  front  of  the  retina,  in  which  there  is  a  clear-cut  hole.  I  have 
seen  three  such  cases  and  in  two  of  them  there  was  a  patch  of  old 
retinochoroidal  atrophy,  The  obvious  explanation  seems  to  be  that 
the  inflammatory  process  in  the  retina  caused  adherence  of  the  vitre- 
ous over  the  patch  itself  and  some  thickening  of  the  vitreous  envelop 
around  the  patch,  and  when  contraction  of  the  vitreous  took  place,  a 
hole  was  torn  in  the  membrane  around  the  site  of  adhesion,  leaving  a 
visible  thickened  rim  to  the  hole. 

Such  holes  in  the  vitreous  might  conceivably  occur  from  tearing 
away  of  the  hyaloid  from  either  an  adherent  patch  on  the  retina  or 
from  the  disc  itself.  That  the  hyaloid  may  be  torn  from  the  disc  so 
as  to  leave  a  hole  is  supported  by  a  specimen  with  suppurative  cyclitis 
which  I  examined  pathologically,  and  found  the  vitreous  contracted, 
and  a  definite  round  hole  in  its  limiting  envelop  just  opposite  the  disc. 
In  the  absence  of  any  visible  choroidoretinitis  it  is  difficult  to  avoid 
the  conclusion  that  this  hole  was  torn  from  the  margin  of  the  disc,  the 
site  at  which,  as  already  noted,  the  vitreous  is  normally  most  adherent 
at  the  posterior  pole  of  the  eye. 

The  only  other  explanation  that  has  been  offered,  so  far  as  I  know, 
for  these  cases,  is  that  a  fibrous  tissue  plaque  has  for  some  reason  or 
other  formed  in  the  vitreous,  as  in  retinitis  proliferans,  and  that  a 
hole  has  developed  in  it,  such  as  is  seen  in  those  curious  fenestrated 
layers  of  fibrous  tissue  met  with  lying  on  the  surface  of  a  retina  which 
has  been  severely  concussed.  Against  such  a  view  I  urge: 

1.  That  in  none  of  my  cases  was  there  any  other  sign  of  retinitis 
proliferans  of  the  ordinary  types,  and 

2.  It  is  very  difficult  to  imagine  how  a  hole  could  develop  in  such  a 
membrane  lying  loose  in  the  vitreous. 

To  sum  up  my  paper — the  specimens  which  I  have  shown  suggest 
or  corroborate  the  following  conclusions: 

1.  The  vitreous  has  some  structure  and  is  not  homogeneous,  and 
this  structure  is  one  of  concentric  lamellation,  as  described  by 
Hanover. 


Detachment  of  the  Vitreous  63 

2.  That  there  is  a  limiting  membrane  to  the  vitreous,  i.  e.,  the 
hyaloid  is  not  a  myth. 

3.  That  under  certain  conditions  degeneration  of  the  vitreous  may 
occur,  and  both  the  hyaloid  and  all  other  structures  of  the  vitreous 
may  disappear. 

4.  That  clinical  cases  are  seen  which  can  only  be  explained  by  sup- 
posing that  such  a  hyaloid  membrane  has  been  thrown  into  folds. 

5.  That  thickening  in  the  hyaloid  may  take  place  as  the  result  of 
inflammatory  processes  occurring  in  the  adjacent  retina,  which  have 
caused  adherence  of  the  vitreous  to  the  retina,  so  that  if  subsequent 
detachment  of  the  vitreous  occurs,  this  limiting  membrane  may  tear 
around  the  edge  of  the  adherent  area,  and  a  hole  in  the  membrane 
may  result  which  is  visible  with  the  ophthalmoscope. 

6.  That  detachment  of  the  vitreous  is  common  during  life,  and  its 
presence  in  pathologic  specimens  is  not  the  result  of  the  fixing  reagent, 
at  any  rate  when  formalin  has  been  used. 

7.  That  if,  from  any  cause,  the  vitreous  has  become  adherent  to 
the  retina  from  injury,  hemorrhage,  or  inflammation,  then,  on  de- 
tachment, the  vitreous  becomes  as  it  were  '* pegged  out"  at  certain 
spots,  and  traction  is  exerted  on  the  retina  which  may  cause  flashes 
of  light  on  movement  of  the  eye,  folding,  detachment,  or  even  holes 
in  the  retina. 

8.  That  detachment  of  the  vitreous  is  a  necessary  precursor  to  cer- 
tain pathologic  conditions,  e.  g.,  punctate  deposits  on  the  retina,  and 
the  peculiar  fan  formations  of  pus  or  fibrous  tissue  which  are  some- 
times found  extending  from  the  optic  disc. 

DISCUSSION 

DR.  M.  FEINGOLD  (New  Orleans,  La.) :  There  is  no  question  that  the  vitre- 
ous is  one  of  the  most  puzzling  organs  in  the  human  body.  Those  of  us  who 
are  daily  using  the  Gullstrand  slit  lamp  can  testify  to  the  fact  that  the  vitreous 
has  some  structure  even  in  the  normal  eye.  We  see  behind  the  lens  a  peculiar 
network,  a  lace-like  structure,  which  in  the  normal  eye  has  almost  no  move- 
ment, even  with  the  microscope  On  the  other  hand,  the  arguments  brought 
out  by  the  paper  certainly  prove  that  the  vitreous  has  a  structure.  Hemor- 
rhages into  the  vitreous  and  pus  infiltration  in  a  great  number  of  cases  tend  to 
show  a  radial  striated  laminated  arrangement,  and  I  have  seen  some  cases  of 
injury  where  the  radial  arrangement  of  the  hemorrhage  into  the  vitreous 
was  a  diagnostic  help,  pointing  to  the  site  of  the  injury,  showing  the  blood  had 
been  scattered  in  special  directions  and  maintained  in  that  position  for  weeks, 
proving  that  the  vitreous  really  had  some  structure. 

As  to  the  question  of  the  structure  of  the  vitreous  derived  from  a  histologic 


64  WILLIAM  LISTER 

specimen,  that  is  an  entirely  different  problem,  because  of  the  point  raised  by 
the  essayist  of  the  difficulties  that  the  eyeball  presents  when  it  comes  to  fixa- 
tion. In  a  paper  published  some  years  ago  from  one  of  the  German  clinics  the 
comparative  value  of  the  different  fixing  agents  was  described;  there  the  fact 
was  dwelt  upon  that  the  choroid  in  formalin  fixation  is  greatly  compressed, 
and  the  explanation  given  was  that  it  was  produced  by  swelling  of  the  vitreous. 
This  goes  to  show  that  we  cannot  at  present,  because  of  the  lack  of  a  multiplic- 
ity of  fixing  agents  that  give  the  same  results,  derive  any  conclusions  as  to 
the  structure  of  the  normal  vitreous  in  vivo.  As  to  the  pathologic  vitreous, 
there  the  changes  are  entirely  different,  and  we  can  easily  see  with  the  Gull- 
strand  apparatus  distinct  movement  of  the  flakes  floating  in  the  vitreous. 
Whether  detachment  occurs  in  vivo  is  difficult  to  say,  and  we  can  only  hope 
for  help  from  this  method ;  but  that  detachment  is  occasionally  found  in  the 
histologic  specimen  there  is  no  doubt.  I  have  in  my  own  sections  seen  detach- 
ment of  the  vitreous  in  which,  between  the  detached  vitreous  and  the  retina,  a 
fluid  was  found  exactly  as  described  by  the  essayist.  I  hope  that  we  shall  in 
the  future  find  new  fixing  agents  by  which  we  will  be  able  to  study  the  normal 
vitreous,  and  that  we  shall  see  results  from  the  examination  of  the  unfixed, 
unhardened  vitreous  with  the  Gullstrand  lamp,  as  has  already  been  started  by 
Vogt. 

DR.  T.  B.  HOLLO  WAY  (Philadelphia) :  I  believe  that  I  am  voicing  the  sen- 
timent of  most  of  us  preserft  this  morning  when  I  say  that  we  must  feel  very 
much  indebted  to  Sir  William  Lister  for  bringing  this  subject  to  our  attention. 
It  has  always  impressed  me  that  the  vitreous  is  one  of  the  particular  portions 
of  the  eye  that  has  been  neglected — at  least  neglected  as  far  as  positive  find- 
ings are  concerned.  We  know  so  little  about  it.  It  was  that  fact  that  made 
me  presumptuous  enough  to  volunteer,  as  did  Dr.  Feingold,  to  assist  in  open- 
ing the  discussion  of  this  subject. 

I  question  whether  any  of  us  today,  as  Sir  William  Lister  has  said,  would 
doubt  but  what  the  vitreous  has  a  very  definite  structure.  We  have  all  seen 
specimens  that  point  very  definitely  toward  a  certain  amount  of  lamination, 
particularly  of  the  peripheral  portion  of  the  vitreous. 

In  regard  to  the  hyaloid,  I  am  perfectly  free  to  confess  that  I  had  always 
regarded  the  hyaloid  membrane  as  definitely  existing  until  I  reviewed  the 
splendid  work  of  Mawas  and  Magitot,  to  which  the  essayist  has  referred,  and 
then  my  faith  became  somewhat  shaken,  but  I  have  never  been  able  to  recon- 
cile its  absence  with  certain  clinicopathologic  findings. 

The  essayist  has  seen  fit  to  refer  to  certain  degenerative  changes  of  the 
retina  and  in  doing  so  has  touched  upon  a  rather  tender  point  in  my  own  ob- 
servations. I  am  referring  to  the  presence  of  cholesterin  in  the  vitreous,  to 
which  he  has  referred.  To  my  mind  the  presence  of  cholesterin  crystals  in  the 
vitreous  is  an  unusual  manifestation  of  the  degeneration  of  this  structure.  I 
think  that  in  the  majority  of  cases  typical  or  atypical  snowball  vitreous 
opacities  are  observed. 

With  reference  to  adhesions  of  the  vitreous  to  the  retina  and  the  produc- 
tion of  holes  in  the  retina,  as  I  understand  Sir  William  Lister,  he  thinks  that  a 
tacking  down  of  the  vitreous  may  occur  after  a  focal  irritation.  Under  these 


Detachment  of  the  Vitreous  65 

circumstances  the  retina  may  be  detached,  or  if  a  tear  results,  it  may  affect,  in 
one  instance,  the  retina,  and  in  another,  the  hyaloid  membrane,  producing 
what  he  designates  as  a  hole.  Personally,  I  believe  I  have  seen  a  tear  of  the 
first  type  in  a  case  which  presented  itself  in  my  service  about  three  or  four 
months  ago,  where  there  was  a  very  definite  lesion  of  this  character  of  the 
horseshoe  type,  associated  with  a  well-marked  patch  of  retinochoroiditis. 

He  also  speaks  of  certain  foldings  of  the  hyaloid.  On  the  records  of  a  case 
that  has  been  under  my  observation  for  some  time,  I  have  made  clinical  notes 
to  the  effect  that  the  clinical  picture  might  well  be  produced  by  a  folding  of 
the  hyaloid  membrane.  The  lesions  were  central  and  subsequently  they 
proved  to  be  proliferative.  However,  I  can  readily  believe  that  such  lesions 
may  occur. 

PROFESSOR  EMILE  GALLEMAERTS  (Brussels,  Belgium):  J'ai  demande"  la 
parole  pour  insister  sur  le  point  souleve  par  le  Docteur  Feingold.  II  n'est  plus 
necessaire  maintenant  de  faire  1'examen  microscopique  d'yeux  enuclees  pour 
etudier  la  structure  du  corps  vitre  a  1'etat  normal  ou  pathologique.  Si  Ton 
examine  1'oeil  vivant  a  1'aide  de  la  slit  lamp  de  Gullstrand,  on  voit  sur  un  fond 
noir,  se  detacher  les  fibrilles  du  corps  vitre;  1'aspect  de  ces  fibrilles  varie,  elles 
s'entr'croisent  et  demontrent  la  structure  reticulaire  du  corps  vitre.  A  1'etat 
pathologique  on  peut  observer  les  alterations  si  bien  decrites  microscopique- 
ment  par  Treacher  Collins;  on  voit  les  fibrilles  changer  d'aspect,  s'epaissir, 
se  raccourcir,  se  condenser.  II  y  a  la  un  chapitre  nouveau  pour  1'etude  du 
corps  vitre\ 

DR.  JOHN  E.  WEEKS  (New  York  City):  Much  light  may  be  thrown 
on  the  structure  of  the  vitreous  body  by  the  careful  study  of. embryonal 
tissue.  The  embryonal  vascular  system  of  the  vitreous  bcpy  and  the 
vascular  system  of  the  retina  develop  from  mesoblastic  tissue  and  they 
both  develop  from  the  same  process  of  mesoblast  that  enters  the  embry- 
onal retinal  fissure.  In  the  study  of  the  embryo  of  the  rabbit  we  will 
find  that  the  outer  surface  of  the  vitreous  is  shaggy,  due  to  minute  proc- 
esses that  extend  from  it  into  the  nerve-fiber  layer  of  the  retina,  as  a  result 
of  the  continuity  of  mesoblastic  tissue.  The  distinctly  shaggy  condition 
of  the  outer  surface  of  the  vitreous  body  in  the  embryo  is  not  present 
beyond  the  ora  serrata,  the  anterior  surface  beyond  this  point  being  appar- 
ently limited  by  the  network  of  capillaries  of  which  the  posterior  part  of  the 
membrana  vascularis  lentis  forms  the  greater  part.  This  part  of  the  vitreous 
body  at  this  stage  rests  against  tissue  that  is  of  epiblastic  origin  and  is  not 
incorporated  with  it.  In  the  early  stages  of  development  of  the  vitreous  body 
blood-vessels  permeate  all  parts  of  it.  These  disappear  as  development  pro- 
gresses, apparently  having  a  very  delicate  framework.  The  capillaries  are 
most  numerous  at  the  periphery  of  the  vitreous  body,  particularly  anteriorly, 
and  here  more  than  anywhere  else  the  vitreous  body  presents  a  retaining 
structure  which  is  apparently  composed  of  any  incomplete  laminae,  more 
closely  associated  near  the  surface  of  the  vitreous  body.  This  laminated 
membrane  in  the  vitreous  body  is  in  effect  a  limiting  membrane.  It  is  not  a 
membrane  that  can  be  seen  with  the  microscope,  as  we  see  the  limiting  mem- 
brane of  the  lens.  If  we  study  the  pathologic  condition  of  the  vitreous  body, 

5 


66  WILLIAM  LISTER 

we  find  that  hemorrhages  extending  into  the  vitreous  do  so  without  regard  to 
a  uniform  structure,  and  that  the  formation  of  fibrous  bands  do  not  follow  any 
plan  of  structure  of  the  vitreous.  However,  in  certain  pathologic  conditions 
an  infiltration  may  follow  lines  that  indicate  an  irregular  structure. 

The  holes  in  the  so-called  limiting  membrane  of  the  vitreous,  I  think,  are 
only  the  result  of  pathologic  material  in  certain  areas. 

DR.  J.  W.  NORDENSON  (Stockholm,  Sweden) :  I  think  we  are  much  in- 
debted to  Sir  William  Lister  for  calling  our  attention  to  the  question  of  the 
detachment  of  the  vitreous,  and  I  only  want  to  point  out  some  details  in  his 
work  where  I  think  there  might  be  some  difference  of  opinion.  There  is,  as 
you  have  heard,  such  a  difference  of  opinion  between  him  and  the  histologists 
who  have  worked  on  the  structure  of  the  vitreous.  I  wish,  in  this  respect,  to 
refer  to  the  work  published  about  thirty  years  ago  by  Gustav  Retzius l  who 
has  shown  that  in  his  opinion  the  vitreous  has  no  real  membranes,  but  that  it 
has  a  laminated  structure.  The  laminae  consist  of  densifications  of  its  fibrillar 
tissue;  and  they  are  not  concentric,  but,  as  he  has  shown,  are  placed  in  a 
sagittal  direction.  These  laminae,  pointed  out  by  him  thirty  years  ago,  have 
also  been  found  by  the  investigators  working  with  the  Gullstrand  slit  lamp.  If 
you  take  these  laminae  into  consideration  you  will  find  an  explanation  not  only 
of  the  clinical  facts  that  Sir  William  Lister  has  described  here,  but  they  also 
seem  to  give  a  clue  to  the  difference  of  opinion  between  him  and  the  French 
investigators,  Mawas  and  Magitot,  who  have  worked  with  the  vitreous.  I  am 
wondering  whether  what  he  calls  a  detachment  of  the  vitreous  might  not  be 
considered  as  a  cleft  or  crevasse  of  the  vitreous  tissue,  and  what  he  calls  the 
detached  hyaloidea  a  densification  of  this  tissue  lying  not  in  a  sagittal  but  in  a 
frontal  plane ;  also  if  the  holes  that  he  has  observed  are  not  places  where  this 
densification  is  absent.  I  think  the  whole  question  is  a  little  difficult  to  grasp 
if  you  speak  about  detachment  of  the  vitreous.  Might  we  not  speak  of  clefts, 
of  the  vitreous?  Then  I  think  the  question  of  the  hyaloid  membrane  would 
not  cause  any  difference  of  opinion  between  histologists  and  clinicians. 

COLONEL  R.  H.  ELLIOT  (London,  England) :  My  interest  in  the  hyaloid 
was  excited  when  I  studied  750  consecutive  cases  of  couching  of  the  lens 
made  by  natives  of  India.  Of  these,  I  submitted  125  globes  to  anatomic 
examination,  and  in  quite  a  considerable  number  a  careful  histologic  examina- 
tion was  made  as  well.  In  all  these  operations  there  was,  first  of  all,  often  a 
perforating  wound  of  the  vitreous  by  the  instrument  used  in  couching;  sec- 
ond, there  was  disturbance  of  the  vitreous  as  a  result  of  the  lens  being  pushed 
bodily  into  it,  and  third,  there  was  septic  infection  of  the  vitreous  in  a  large 
number  of  cases.  I  want  you  to  notice  one  point  especially,  viz.,  that  in  the 
specimens  of  my  series  (which  are  lodged  in  the  museum  of  the  Royal  College 
of  Surgeons  of  England)  the  infection  is  often  localized,  sometimes  by  spread 
along  definite  planes,  sometimes  by  strict  localization  to  a  definite  area  of  the 
vitreous.  Now  it  seems  incredible  that  this  could  happen  in  any  but  an 
organized  structure. 

There  is  not  time  to  take  Sir  William  Lister's  points  one  by  one,  but  there 

^iologische  Untersuchungen,  No.  VI,  Stockholm,  1896. 


Detachment  of  the  Vitreous  67 

are  two  or  three  I  would  especially  like  to  give  my  support  to.  First,  in  a  very 
definite  manner  my  specimens  indicated  that  the  vitreous  has  a  definite  struc- 
ture. Then,  again,  I  would  like  to  say  a  word,  not  only  from  my  examination 
of  the  eyes  I  have  mentioned,  but  also  from  a  clinical  point  of.  view,  of  the 
existence  of  a  definite  anterior  hyaloid  membrane.  You  may  speak  of  it  as  a 
membrane,  or  as  a  thickening  of  the  anterior  layers,  but  there  is  a  definite 
hyaloid  membrane,  and  that  hyaloid  membrane  is  a  very  definite  protection 
(both  mechanical  and  anti-infective)  to  the  surgeon  in  a  large  number  of 
operations,  and  especially  in  those  for  cataract. 

The  question  of  the  existence  of  clinical  detachment  of  the  vitreous  is  my 
next  point.  I  sectioned  a  number  of  these  couched  eyes  shortly  after  their 
removal,  having  first  frozen  them  in  ice  and  salt.  Detachment  of  the  vitre- 
ous, as  Sir  William  Lister  has  detailed  it  to  you,  was  common  in  those  speci- 
mens. On  that  point  I  am  emphatic. 

I  speak  of  these  matters  particularly  from  the  point  of  view  of  the  clinician. 
It  is  important  that  we  should  have  a  clear  view  of  the  structure  of  the  vitre- 
ous, and  that  we  should  recognize  it  as  an  organized  structure  with  a  definite 
limiting  membrane.  If  we  are  not  clear  on  this  subject,  our  views  will  have  a 
mischievous  tendency  in  our  surgery. 

PROFESSOR  IGNACIO  BARRAQUER  (Barcelona,  Spain):  In  my  opinion  the 
vitreous  is  a  semisolid  body,  surrounded  by  a  membrane  or  thickening  of  this 
structure,  resistant  enough  to  keep  it  isolated  from  the  eye,  and  to  pass  it 
from  hand  to  hand  without  losing  its  spheroidal  form,  but  it  can  be  liquefied 
by  compressing  it.  Its  structure  is  fibrillar,  and  with  Gullstrand's  lamp  and 
the  binocular  microscope  of  Zeiss  its  fibers  can  be  seen  clearly  contracted  after 
an  injury.  The  cicatricial  retraction  of  those  fibers  is  the  cause  of  the  detach- 
ment of  the  vitreous  and  sometimes  of  the  retina.  All  detachments  of  the 
retina  after  cataract  extraction  have  this  origin.  It  is  indispensable,  therefore, 
to  avoid  compression  of  the  eye  during  cataract  operations,  as  well  as  the 
introduction  of  pointed  instruments  into  its  chambers.  By  doing  this  we  shall 
see  the  disappearance  of  post-operative  retinal  detachments  consecutive  to 
wounds  of  the  vitreous.  One  of  the  most  dangerous  operations  is  the  cap- 
sulotomy,  and  also  discission  of  the  secondary  cataract,  as  by  them  the  vitre- 
ous is  nearly  always  wounded. 

DR.  F.  PARK  LEWIS  (Buffalo,  N.  Y.) :  There  are  two  points  I  would  like 
to  add  in  supplement  to  Dr.  Lister's  observations.  The  manner  in  which 
the  vitreous  has  been  examined  heretofore  is  the  same  as  that  which  has  been 
applied  to  other  ocular  structures.  It  has  been  placed  in  hardening  fluid 
and  sectioned  and  observations  made.  The  vitreous  is  90  per  cent,  fluid. 
When  its  contents  are  abstracted,  the  skeleton  only  remains  and  the  rela- 
tionships of  its  parts  are  wholly  changed  by  compression,  giving  a  wholly 
inaccurate  impression  of  its  anatomy.  Certain  facts,  however,  can  be  de- 
duced from  an  examination  even  macroscopically  of  the  vitreous  when  it  is 
removed  from  the  eyeball.  The  entire  lenticular  system  comes  out  en  masse. 
By  placing  this,  consisting  of  the  vitreous  body  and  the  crystalline  lens,  in 
slightly  acidulated  water  it  imbibes  the  fluid  and  its  separate  parts  are  more 
clearly  brought  into  view.  It  will  then  be  found  that  the  vitreous  is  composed 


68  WILLIAM  LISTER 

of  an  outer  exceedingly  elastic  membrane  which  balloons  out  to  nearly  one- 
third  its  normal  size.  But  even  when  hardened  and  sectioned  and  placed 
under  the  microscope  it  will  be  found  that  the  skeletonized  remnant  is  com- 
posed of  a  number  of  fibers  which  curl  upon  themselves  like  shavings,  showing 
that  the  internal  structure  of  the  vitreous  is  composed  of  elastic  tissues. 
These  two  facts  should  be  noted,  as  essential  conclusions  may  be  drawn  from 
them. 

One  other  point  must  be  mentioned.  I  have  said  that  our  methods  of 
examining  a  fluid  body  by  first  extracting  the  fluid  in  it  is  essentially  in- 
correct. A  method  which  I  have  found  of  great  value  is  to  coagulate  this 
body  without  extracting  its  substance.  By  placing  it  in  a  water-box  with  an 
optically  perfect  glass  cover  its  structure  may  be  definitely  determined  by  the 
aid  of  the  Gullstrand  light  and  the  corneal  microscope.  Such  specimens  I 
have  here  in  demonstration,  and  I  will  also  show  a  photograph  in  which  can 
be  definitely  shown  some  of  the  tubules  through  which  the  nutrition  of  the 
vitreous  is  maintained. 

DR.  F.  H.  VERHOEFF  (Boston,  Mass.) :  I  have  frequently  observed  separa- 
tion of  the  vitreous  on  examination  of  pathologic  specimens,  and  can  confirm 
all  the  observations  of  the  essayist  except  the  finding  of  holes  in  the  hyaloid. 
I  have  no  doubt  of  their  existence,  but  I  have  never  observed  them.  I  have 
not  made  a  systematic  study  of  the  subject  and,  therefore,  am  not  prepared 
to  express  an  opinion  as  to  its  exact  importance. 

One  of  the  important  things  about  the  vitreous  which  we  do  not  know  is 
exactly  how  liquefaction  may  come  about.  If  we  could  produce  liquefaction 
of  the  vitreous  at  will,  we  would  be  doing  an  important  thing  in  certain  cases 
where  we  have  vitreous  opacities.  I  have  tried,  but  have  not  succeeded. 
Separation  of  the  hyaloid  membrane  may  play  a  part  in  certain  cases  of  sec- 
ondary glaucoma.  In  case  of  a  very  small  sarcoma  of  the  choroid  I  found  the 
hyaloid  membrane  separated  from  the  retina,  allowing  the  vitreous  and  lens 
to  be  pushed  forward,  causing  obliteration  of  the  anterior  chamber. 

After  any  method  of  fixation  if  you  stain  the  vitreous  deeply  the  hyaloid 
membrane  is  seen  with  sufficient  distinctness,  it  seems  to  me,  as  to  leave  no 
doubt  of  its  existence.  If  you  fix  the  retina  in  Zenker's  fluid  and  then  stain  it 
in  Mallory's  connective-tissue  stain,  the  hyaloid  membrane  will  show  up  as 
definitely  as  the  lens  capsule.  It  does  not  send  projections  into  the  retina, 
but  is  entirely  distinct,  and  can  easily  be  pulled  off  from  the  latter.  One  rea- 
son perhaps  that  there  is  this  difference  of  opinion  as  to  the  existence  of  the 
hyaloid  is  that  the  vitreous  does  send  very  fine  fibers  into  it,  but  that  is  no 
reason  for  not  regarding  it  as  membrane.  The  anterior  part  of  the  hyaloid 
membrane,  that  is,  the  part  that  leaves  the  retina  and  extends  behind  the  lens, 
possibly  may  play  a  part  in  the  causation  of  primary  glaucoma.  Thus,  if  its 
permeability  should  become  altered  so  there  was  an  increased  osmotic  pressure 
behind  it,  the  anterior  chamber  would  be  shallowed. 

MR.  E.  TREACHER  COLLINS  (closing) :  I  do  not  wish  to  take  upon  myself  to 
reply  in  behalf  of  Sir  William  Lister,  but  I  would  like  to  make  a  few  remarks 
myself. 

I  quite  agree  with  Dr.  Weeks  that  it  is  much  easier  to  examine  the  structure 


On  Diaphragm  Lamps  in  Ophthalmology  69 

of  the  vitreous  in  the  fetal  eye  than  in  the  fully  developed  eye.  A  good  many 
years  ago  I  examined  fetal  eyes  hardened  in  Miiller's  fluid  and  I  came  to  the 
conclusion  not  only  that  the  hyaloid  membrane  is  as  definite  a  structure  as 
the  capsule  of  the  lens,  but  that  the  membrane  in  the  fetal  eye  has  cells  in  it 
scattered  widely  at  definite  distances.  I  think  I  will  be  able  to  demonstrate 
that  to  you  with  lantern  slides  made  from  my  specimens. 

Further,  the  vitreous  of  the  fetal  eye  is  permeated  throughout  by  a  net- 
work of  fibers  with  a  lot  of  little  fine,  nodular  points  where  they  cross  that 
take  on  the  nuclear  stain.  We  do  not  know  what  they  are;  they  are  smaller 
than  any  known  nucleus  of  a  cell.  These  nuclear  staining  bodies  disappear  in 
the  adult,  but  I  think  sometimes  a  few  persist  and  float  about  in  the  vitreous, 
and  that  the  muscse  volitantes  are  just  remnants  of  this  network  of  fibers.  I 
have  had  sections  of  the  fetal  vitreous  under  the  microscope,  and  at  the  same 
time  have  had  float  into  my  field  of  vision  my  own  muscae,  and  have  thus  been 
able  to  compare  the  appearance  of  floating  vitreous  opacities  with  the  net- 
work in  the  fetal  eye. 

One  of  the  most  interesting  points  in  Sir  William  Lister's  paper  is,  I  think, 
what  he  describes  as  "holes"  in  the  hyaloid.  In  one  of  the  cases  in  my  own 
clinic  the  appearance  seen  seemed  to  me  to  be  unexplainable  on  any  other 
ground.  One  of  these  "holes "  was  somewhat  anterior  to  the  retina  and  moved 
about  in  movements  of  the  eye.  I  took  it  that  the  place  where  the  vitreous 
was  normally  attached  to  the  optic  disc  had  become  detached  and  showed  as  a 
round  hole. 


ON  DIAPHRAGM  LAMPS  IN  OPHTHALMOLOGY 

PROF.  ALLVAR  GULLSTRAND 

Upsala,  Sweden 

The  examination  of  the  living  eye  for  diagnostic  purposes  as  well  as 
for  scientific  investigations  is  highly  facilitated  by  a  suitable  illumina- 
tion of  the  field,  and  the  best  results  are  obtained  when  the  distribu- 
tion of  light  and  shadow  can  be  perfectly  controlled.  To  obtain  this 
effect  it  is  necessary  for  a  sharp  optical  image  of  a  bright  and  uniform 
source  of  light  to  be  projected  on  the  most  favorable  place  and  other 
light  to  be  shut  out  from  the  field.  The  latter  condition  requires  not 
only  a  dark  room,  but  also,  in  certain  methods  of  examination,  the 
shutting  out  of  light  that  is  reflected  regularly  by  the  refracting  sur- 
faces of  the  eye  or  diffusely  by  the  substance  of  the  cornea  and  of  the 
lens. 

Thus  there  are  two  conditions :  the  source  of  light  must  be  uniform 
and  sharply  limited,  with  a  high  specific  intensity,  and  a  sharp  optical 
image  of  this  source  of  light  must  be  procured.  As  is  now  well  known, 


70  ALLVAR  GULLSTRAND 

the  slit  lamp  and  the  aspheric  lens  (an  aplanatic  lens  with  a  non- 
spheric  surface  of  revolution)  answer  these  conditions.  But  the  slit 
lamp  is  not  the  only  suitable  lamp.  What  is  wanted  is  a  uniform 
source  of  light  of  high  specific  intensity  adequately  combined  with  a 
diaphragm  through  an  appropriate  optical  system.  The  slit  lamp  is, 
therefore,  only  a  special  type  of  the  diaphragm  lamp.  When  the 
diaphragm  has  a  circular  aperture,  another  type  results  for  which  I 
suggest  the  name  hole  lamp. 

SLIT  LAMPS 

That  the  first  diaphragm  lamp  for  ophthalmologic  use  was  a  slit 
lamp  is  due  to  practical  reasons.  Of  the  then  available  light  sources, 
only  the  crater  of  the  arc  lamp  and  the  glowing  filament  of  the  Nernst 
lamp  had  a  sufficient  luminosity  combined  with  a  sufficient  area  of 
uniformity.  As  the  latter  represented  the  simpler  and  more  easily 
available  means  and  proved  practicable,  I  preferred  it.  As  a  rule, 
if  the  greatest  effect  is  desirable,  the  shape  of  the  diaphragm  is  de- 
termined by  the  shape  of  the  source  of  light,  and  therefore  with  the 
Nernst  lamp  the  diaphragm  must  be  a  slit.  The  Nernst  slit  lamp 
consists  mainly  of  a  tube  which  contains  in  one  end  the  Nernst  lamp, 
and  which  is  closed  at  the  other  end  by  a  plate  carrying  a  slit  of 
variable  width.  By  means  of  a  lens  or  a  system  of  lenses  an  optical 
image  of  the  glowing  filament  is  procured  which,  by  appropriate 
mechanical  appliances,  can  be  brought  to  coincide  with  the  slit.  At 
first  I  used  this  lamp  for  ophthalmometric  investigations,  and  I  have 
described  it  in  the  third  edition  of  Helmholtz's  handbook  of  physio- 
logic optics.  Then,  on  my  suggestion,  the  aspheric  lens  was  calcu- 
lated by  M.  v.  Rohr  and  brought  on  the  market  by  Carl  Zeiss  in  Jena. 
Using  this  lens  for  focal  illumination  with  the  slit  lamp  I  immediately 
verified  the  superiority  of  the  method,  as  I  could  see,  for  example, 
the  structure  of  the  normal  vitreous  body. 

During  the  war  the  fabrication  of  the  Nernst  lamp  ceased  and  good 
Nernst  filaments  cannot  be  bought  now.  Therefore  in  the  instru- 
ments of  Zeiss  the  Nernst  lamp  has  been  replaced  by  a  nitra  lamp, 
which  consists  of  a  glowing  narrow  spiral  of  tungsten  filament  in  a 
glass  bulb  filled  with  an  inert  gas.  This  lamp  has  several  disad- 
vantages as  compared  with  the  Nernst  lamp:  the  spiral  is  not  a 
uniform  source  of  light,  and  it  is  not  always  straight;  the  refraction 
in  the  glass  of  the  bulb  deteriorates  the  optical  image  projected  in 
the  slit;  and  the  lamp  demands  a  strong  current  with  a  low  voltage, 


On  Diaphragm  Lamps  in  Ophthalmology  71 

so  that  an  encumbering  resistance  must  be  used  in  the  circuit  in  con- 
nection with  an  ordinary  supply  of  electricity.  For  certain  methods, 
e.  g.,  those  of  reflexless  ophthalmoscopy,  it  is  not  essential  that  the 
source  of  light  is  uniform  and  the  slit  filled  out  by  its  optical  image, 
so  that  the  lamp  can  directly  replace  the  Nernst  lamp,  but  for  focal 
illumination  an  optical  image  of  a  uniformly  bright  slit  is  of  so  high 
value  that  another  device  is  preferable.  If  the  lens  is  connected  with 
the  lamp  by  an -arm  (a  device  of  Henker),  a  narrow  beam  of  light  is 
sufficient  and  in  this  case  it  is  not  necessary  that  the  optical  image  of 
the  spiral  coincides  with  the  slit.  It  can  be  projected  on  the  lens 
by  pushing  the  lamp  deeper  in  the  tube,  whereby  the  optical  image  of 
the  slit  becomes  uniformly  bright. 

For  certain  methods  of  reflexless  ophthalmoscopy  a  small  incan- 
descent lamp  is  a  sufficient  source  of  light.  The  filament  must  be 
straight,  and  an  optical  image  of  it  is  projected  in  a  slit  in  the  same 
way  as  with  the  Nernst  lamp. 

HOLE  LAMPS 

^Nowadays  there  is  another  lamp  with  sufficient  specific  intensity 
on  the  market,  namely,  the  pointolite  lamp,  which  is  a  tungsten  arc 
lamp,  inclosed  in  a  glass  bulb  containing  an  inert  gas  at  low  pressure. 
There  are  several  types,  but  the  smallest  of  them  is  sufficient  for 
ophthalmologic  purpose.  The  lamp  is  lighted  by  a  strong  ionization 
current  of  short  duration,  but  demands  only  a  current  of  less  than  0.5 
ampere  when  burning.  Moreover,  the  voltage  is  higher  than  that 
of  the  nitra  lamp,  and  as  a  consequence  the  necessary  resistance  is 
less  encumbering.  But  the  greatest  advantage  over  the  nitra  lamp 
is  the  perfect  uniformity  of  the  light  source,  which  is  a  ball  of  tungsten 
used  as  an  anode.  If  an  optical  image  of  this  ball  is  projected  in  a 
circular  aperture,  an  ideal  hole  lamp  can  be  obtained.  The  glass  bulb 
is  sealed  up  on  the  top,  and  when  the  lamp  has  been  used  some  time, 
deposits  from  volatilized  tungsten  are  seen  here  on  the  inside.  It  is 
consequently  preferable  to  mount  the  lamp  perpendicularly  to  the 
optical  axis  of  the  tube.  In  this  position  the  optical  image  of  the  ball 
is  not  appreciably  deteriorated  by  the  refraction  in  the  glass  bulb, 
and  the  light  is  less  weakened  by  the  deposits.  But  for  many  pur- 
poses the  lamp  can  also  be  mounted  along  the  axis  in  the  .same  way 
as  the  Nernst  lamp.  It  can,  in  these  cases,  replace  the  Nernst  lamp 
in  the  ordinary  slit  lamp.  Though  the  slit  is  then  not  filled  out  by 
the  optical  image  of  the  ball,  and  though  only  a  part  of  this  image  is 


72  ALLVAR  GULLSTRAND 

used,  this  combination  answers  well  for  many  methods.  Finally, 
with  a  special  arrangement,  the  lamp  can  be  used  in  a  slit  lamp  for 
focal  illumination  when  its  optical  image  is  projected  on  the  lens. 

FOCAL  ILLUMINATION 

The  superiority  of  diaphragm  lamps  for  focal  illumination  is  so 
great  that  other  lamps  should  never  be  used  for  this  method  of  ex- 
amination. In  every  clinical  case  it  can  be  expected  that  something 
more  can  be  seen  by  using  the  aspheric  lens  in  connection  with  these 
lamps  than  with  ordinary  lamps  and  lenses.  For  current  clinical  use 
it  is  not  desirable  to  lose  time  by  immobilizing  the  head  of  the  patient 
on  a  support  for  the  chin.  If  this  is  not  done,  a  rather  wide  cone  of 
light  is  necessary  to  allow  for  the  motions  of  the  patient's  head.  For 
this  reason  the  optical  image  of  the  source  of  light  has  to  be  projected 
in  the  diaphragm,  as  in  the  original  Nernst  slit  lamp,  and  the  uni- 
formity of  the  source  of  light  is  a  great  advantage. 

The  focal  illumination  with  diaphragm  lamp  and  aspheric  lens  de- 
mands a  certain  amount  of  skill,  but  is  soon  learned  with  a  little 
practice.  The  lens  is  to  be  held  with  its  most  curved  surface  turned 
to  the  light  at  a  distance  of  about  40  cm.  from  it,  and  perpendicularly 
to  the  ray  that  passes  through  its  center,  so  that  the  diaphragm  is 
situated  on  the  optical  axis  of  the  lens.  That  this  is  really  the  case 
can  be  controlled  by  projecting  an  optical  image  of  the  diaphragm 
on  the  cornea.  This  position  of  the  lens  once  found,  the  only  diffi- 
culty consists  in  moving  the  lens  parallel  to  itself,  as  the  optical  image 
is  projected  deeper  in  the  eye. 

However  insignificant  this  difficulty  is,  the  device  of  Henker  to  fix 
the  lens  on  an  arm  in  connection  with  the  lamp  has  probably  con- 
tributed to  render  the  method  more  accessible  to  oculists.  With  this 
device  the  immobilization  of  the  patient's  head  by  a  support  for  the 
chin  is  desirable,  but  this  complication  offers  an  advantageous  com- 
pensation in  the  possibility  of  using  the  microscope  for  examination. 
As  a  narrow  beam  of  light  is  sufficient,  the  optical  image  of  the  source 
of  light  can,  in  the  way  already  described,  be  projected  on  the  lens, 
whereby  the  nitra  lamp  renders  the  optical  image  of  the  slit  perfectly 
uniform. 

When  the  pointolite  lamp  is  substituted  for  the  nitra  lamp  in  this 
apparatus,  the  optical  image  of  the  slit  is  not  uniformly  bright,  the 
middle  seeming  darker  than  the  ends.  This  inconvenience  is  caused 
by  the  spheric  aberration  of  the  lens  system  contained  in  the  lamp 


On  Diaphragm  Lamps  in  Ophthalmology  73 

tube  in  connection  with  the  smallness  of  the  glowing  ball,  and  can  be 
avoided  by  a  special  construction  in  which  the  distance  between  the 
lens  system  and  the  slit  is  reduced  to  a  minimum. 

The  slit  lamp,  with  the  device  of  Henker  and  the  Nernst  lamp,  the 
nitra  lamp,  or,  for  certain  investigations,  an  arc  lamp  as  source  of 
light,  has  enabled  Koeppe  and  Vogt  to  create  a  whole  new  "branch  of 
ophthalmology,  the  microscopy  of  the  living  eye.  This  is  not  the 
place  to  enter  on  the  details  of  the  results  already  obtained  or  to  be 
expected  by  further  investigations,  but  the  modifications  of  the 
illuminating  system  ought  to  be  mentioned.  Vogt  has  insisted  on 
the  use  of  a  very  narrow  beam  of  light  for  facilitating  the  localization 
in  the  third  dimension.  But  as  the  slit  grows  smaller  the  chromatic 
aberration  of  the  aspheric  lens  grows  more  disturbing.  For  this 
reason  an  achromatic  combination  of  lenses  was  preferred  to  the 
aspheric  lens.  Such  a  substitution  is  possible  because  a  small 
aperture  is  sufficient  and,  indeed,  in  some  cases  desirable  for  micro- 
scopic examination.  Koeppe  has  completed  the  device  of  Henker 
with  a  tube  which  shuts  off  the  light  reflected  in  the  interior  of  the  lamp 
tube,  with  certain  light  filters,  and  with  a  mirror  which  facilitates  the 
examination  by  giving  the  light  that  forms  the  optical  image  of  the 
slit  another  direction  than  that  of  the  optical  axis  of  the  instrument. 

Moreover,  for  the  microscopic  examination  of  the  angle  of  the  an- 
terior chamber  Koeppe  has  devised  both  a  hydrodiascopic  chamber 
and  a  suitable  contact  lens.  Another  contact  lens,  which  makes  the 
eye  highly  hypermetropic,  has  enabled  him  to  use  the  microscope  for 
the  examination  of  the  deeper  parts  of  the  vitreous  and  of  a  certain 
area  of  the  retina.  Finally,  with  a  third  contact  glass  of  annular 
shape  and  containing  a  conical  reflecting  surface,  he  obtains  the 
necessary  illumination  for  ultramicroscopy  of  the  cornea  with  a  dark 
field.  He  also  uses  polarized  light  for  the  microscopic  examination 
of  the  living  eye. 

SIMPLE  CENTRIC  OPHTHALMOSCOPY 

Under  this  name  I  have  described  a  method  of  ophthalmoscopy  of 
great  value  for  current  clinical  work,  and  for  which  the  hole  lamp  can 
be  used  as  well  as  the  slit  lamp.  In  ordinary  ophthalmoscopy  by  the 
direct  method  the  corneal  reflex  makes  it  impossible  to  see  the  macula 
and  neighboring  parts  of  the  fundus  in  the  direction  of  the  axis  of  the 
eye.  Even  though  the  pupil  be  dilated,  a  certain  decentration  of  the 
hole  of  the  mirror  in  respect  to  this  axis  is  necessary  to  avoid  the  dis- 


74  ALLVAR  GULLSTRAND 

turbing  corneal  reflex,  when  this  part  of  the  fundus  is  examined,  and 
this  decentration  is  sufficient  to  deteriorate  the  optical  image  of  the 
fundus,  the  refraction  of  the  light  being  less  regular  in  the  excentric 
parts  of  the  surfaces  of  the  eye.  But  the  diaphragm  lamp  affords  a 
means  of  suppressing  the  corneal  reflex  and  enabling  the  ophthalmo- 
scopic  examination  of  the  central  parts  of  the  fundus  without  any 
decentration  of  the  hole  of  the  mirror  in  respect  to  the  axis  of  the  ex- 
amined eye.  In  the  light  reflected  by  the  mirror  the  hole  acts  as  an 
opaque  body  and  throws  a  shadow.  If  the  source  of  light  is  suffi- 
ciently small,  a  full  shadow  of  considerable  extension  can  be  obtained, 
and  to  suppress  the  corneal  reflex  it  is  sufficient  that  the  center  of 
curvature  of  the  cornea  (more  exactly,  its  evolute)  is  situated  within 
this  full  shadow.  Thus,  if  a  diaphragm  lamp  is  used  as  source  of  light 
for  ophthalmoscopy  by  the  direct  method,  the  corneal  reflex  can  be 
extinguished  by  an  adequate  movement  of  the  mirror.  The  observer 
sees  a  bright  spot  on  the  fundus  and  the  corneal  reflex.  If  care  is 
taken  that  his  own  nose  does  not  throw  any  shadow  on  the  mirror, 
he  needs  only  move  the  mirror  so  that  the  spot  on  the  fundus  is  cen- 
tered on  the  corneal  reflex  to  see  the  latter  vanish.  Looking  through 
the  central  parts  of  the  refracting  surfaces  of  the  eye  he  then  sees  more 
details  in  the  macula  and  in  its  neighborhood  than  he  can  see  with 
the  ordinary  method.  He  can  also  perform  the  examination  without 
dilatation  of  the  pupil  in  cases  where  nothing  is  seen  of  the  macula 
with  the  ordinary  method.  To  obtain  a  field  of  reasonable  extension 
the  mirror  should  be  concave,  with  a  rather  short  radius  of  curvature 
and  a  narrow  hole.  The  small  mirror  of  Morton's  ophthalmoscope 
answers  well. 

This  method  again  demands  a  certain  amount  of  skill  which,  how- 
ever, is  easily  acquired  by  a  little  practice.  Its  advantages  induce  me 
to  give  here  some  hints.  An  ophthalmoscopist  who  is  able  to  give  the 
mirror  the  correct  position  after  he  has  approached  the  patient  till 
the  two  fronts  are  in  contact  will  meet  with  no  difficulties  if  he  tries 
the  method  the  first  time  on  a  case  with  dilated  pupil.  But  many 
oculists  are  accustomed  not  to  approach  the  patient  until  they  have 
seen  the  pupil  red  by  throwing  light  in  it  at  a  distance  of  some  15  or 
20  cm.  If  this  is  the  case,  the  lamp  must  be  placed  so  far  off  that 
the  cone  of  light  extends  from  the  patient's  eye  to  the  point  from 
which  the  examiner  desires  to  see  the  pupil  red.  If  the  pupil  is  dilated, 
the  extinguishing  of  the  corneal  reflex  by  appropriate  movements  of 
the  mirror  is  soon  learned.  The  illuminated  part  of  the  fundus  shows 


On  Diaphragm  Lamps  in  Ophthalmology  75 

a  darker  spot,  which  is  situated  in  its  center  if  no  shadow  from  the 
nose  of  the  observer  is  thrown  upon  the  mirror,  and  as  soon  as  this 
darker  spot  is  centered  on  the  corneal  reflex,  the  latter  vanishes. 
The  spot  is  a  half  shadow  from  the  hole  of  the  mirror  and  can  be 
avoided  by  bringing  the  lamp  to  a  distance  of  12  to  15  cm.  and  by 
using  an  angle  of  incidence  of  about  45  degrees  on  the  mirror.  In 
this  way  the  method  gives  the  best  results,  but  also  offers  greater 
difficulties.  The  short  distance  diminishes  the  width  of  the  cone 
of  light  at  the  place  of  the  mirror,  so  that  the  observer  must  learn  to 
find  the  correct  position  of  the  ophthalmoscope  after  having  ap- 
proached the  patient;  and  the  great  angle  of  incidence  causes  a 
shadow  of  his  nose  on  the  mirror  and  a  consecutive  diminution  of  the 
illuminated  part  of  the  fundus,  if  special  care  is  not  taken.  As  in 
ordinary  ophthalmoscopic  work  a  smaller  angle  of  incidence  is  used, 
it  may  be  necessary  to  change  the  habitual  position  of  the  ophthal- 
moscope in  respect  to  one's  own  face.  The  new  position  is  easily 
found  out  by  using  the  large  angle  of  incidence  and  a  greater  distance 
of  the  lamp.  The  shadow  from  one's  nose  on  the  mirror  is  then  seen 
on  the  form  of  the  illuminated  part  of  the  fundus. 

I  have  entered  upon  these  details  because  the  superiority  of  the 
method  is  so  evident  that  nobody  who  has  learned  it  will  voluntarily 
use  other  lamps  for  ophthalmoscopy  by  the  direct  method.  The 
slit  lamp  affords  a  somewhat  greater  field  than  the  hole  lamp. 

DIAPHRAGM  LAMPS  IN  OTHER  METHODS  OF  EXAMINATION  WITH  A 

MIRROR 

For  the  examination  of  the  transparent  media  of  the  eye  by  transil- 
lumination  diaphragm  lamps  are  unrivaled.  Fine  dust-like  opacities 
of  the  vitreous  afford  a  striking  example.  It  is  well  known  that  by 
the  ordinary  method  such  opacities  can  be  seen  with  the  plane  mirror 
in  cases  where  nothing  is  seen  if  a  concave  mirror  is  used.  The  usual 
explanation  is  that  the  light  reflected  by  the  concave  mirror  is  too 
strong,  but  the  real  cause  is  that  the  plane  mirror  illuminates  a 
smaller  area  of  the  fundus.  Since  this  illuminated  area  serves  as  a 
source  of  light,  and  as  shadows  are  the  more  conspicuous  the  smaller 
the  source  of  light  used,  it  is  obvious  a  priori  that  the  diaphragm  lamp 
must  give  the  best  results.  It  is  easy  indeed  to  prove  the  sensibility 
of  the  method.  If  the  lamp  is  placed  at  a  distance  of  about  40  cm. 
and  a  plane  perforated  mirror  with  a  narrow  hole  and  with  a  convex 
glass  of  10  or  12  diopters  behind  it  is  used,  it  is  often  possible  to  see 


76  ALLVAR  GULLSTRAND 

shadows  which  are  caused  by  the  distribution  of  the  fluid  moistening 
the  cornea,  and  which  change  when  the  latter  is  wiped  by  the  eyelid. 
Accordingly,  opacities  of  the  vitreous  that,  by  the  ordinary  method, 
are  seen  only  with  the  utmost  difficulty  as  finest  dust,  appear  as  a 
sharply  defined  network. 

In  skiascopy  the  most  reliable  results  are  obtained  when  a  trans- 
parent unperf orated  mirror  is  used.  A  hole  in  the  mirror  always 
causes  a  shadow  which  complicates  the  phenomena  in  the  neighbor- 
hood of  the  point  of  reversal,  and  which  makes  it  impossible  to  find 
the  refraction  in  the  central  part  of  the  pupil.  Therefore  a  plate  of 
glass  with  plane  parallel  faces  is  the  best  mirror,  and  the  loss  of  re- 
flected light  is  supplied  by  the  specific  intensity  of  the  diaphragm 
lamp.  This  method  can  be  regarded  as  an  evolution  of  the  method  of 
Jackson  or  that  of  Wolff  accordingly  as  the  hole  lamp  or  the  slit  lamp 
is  used. 

If  a  hole  of  small  diameter  is  used  as  diaphragm  and  the  mirror  con- 
sists of  a  thin  glass  plate  fixed  in  a  position  which  allows  the  optical 
image  of  the  hole  to  coincide  with  the  observer's  pupil,  the  sensibility 
of  the  method  is  highly  increased  and  allows  the  examination  of  the 
aberration  of  the  eye  and  of  pathologic  asymmetry.  I  have  described 
this  method  under  the  name  of  objective  stigmatoscopy  in  Helmholtz's 
handbook.  With  a  diameter  of  only  J/£  mm.  the  dilatation  of  the 
pupil  can  be  avoided  in  many  cases.  A  diameter  of  1  mm.  gives 
excellent  results  if  the  pupil  is  dilated. 

TRANSILLUMINATION  OF  THE  BULBUS 

My  successor  in  the  chair  of  ophthalmology  in  Upsala,  Professor 
Lindahl,  has  described  a  new  method  of  transillumination  of  the  bul- 
bus  with  a  Nernst  hole  lamp.  He  substituted  a  hole  on  the  apex  of  a 
cone  for  the  slit  in  a  Nernst  slit  lamp,  and  used  this  lamp  at  first  in 
the  ordinary  way,  bringing  the  border  of  the  hole  in  contact  with  the 
scleral  conjunctiva  in  order  to  see  whether  the  red  light  in  the  pupil 
was  weakened  by  a  tumor.  But  he  found  that  the  intensity  of  the 
light  allows  another  method.  If  the  cone  of  light  is  directed  in  the 
pupil,  the  illuminated  part  of  the  fundus  constitutes  a  source  of  light 
sufficiently  intense  to  show  directly  the  shadow  of  a  tumor  and, 
moreover,  the  shadow  of  the  ciliary  body  on  the  sclera,  which  appears 
brilliantly  red.  Thus  Lindahl's  method  is  an  inversion  of  the  old 
method  for  diagnosing  tumors.  As  might  be  expected  from  the 
shape  of  the  diaphragm,  the  pointolite  lamp  has  proved  superior  to  the 


On  Diaphragm  Lamps  in  Ophthalmology  77 

Nernst  lamp  in  Lindahl's  instrument.  A  rather  large  area  of  the 
fundus  being  illuminated,  the  source  of  light  for  the  transillumination 
is  large,  and  shadows  on  the  sclera  can  be  expected  only  from  opaque 
bodies  situated  near  this  membrane.  But  the  ora  serrata  is  dis- 
tinctly seen  and,  as  a  rule,  the  ciliary  processes  throw  a  visible 
shadow. 

CENTRIC  REFLEXLESS  OPHTHALMOSCOPY 

Before  the  construction  of  the  slit  lamp  the  reflexless  ophthal- 
moscopy,  developed  principally  by  Thorner,  was  unable  to  give  the 
best  possible  optical  image  of  the  fundus,  inasmuch  as  the  light  that 
entered  the  eye  of  the  observer  had  to  be  refracted  in  an  excentric 
part  of  the  optical  system  of  the  examined  eye.  For  the  same  reason 
the  maximum  effect  of  stereoscopy  could  not  be  obtained.  If  the  light 
that  enters  the  observer's  eye  has  to  pass  through  the  central  part 
of  the  pupil  of  the  examined  eye,  it  can  be  shown  that  the  light  which 
illuminates  the  fundus  must  pass  through  a  peripheral  zone  which, 
to  avoid  the  light  reflected  diffusely  in  cornea  and  lens,  must  be  the 
narrower,  the  greater  the  ophthalmoscopic  field  that  is  desired.  This 
involves  the  use  of  a  source  of  light  with  high  specific  intensity  and 
necessitates  the  projection  of  an  optical  image  of  it  in  the  plane  of  the 
pupil.  It  is  not  necessary  that  this  optical  image  be  small,  as  the 
superfluous  part  of  it  can  be  projected  on  the  iris,  but  the  optical 
image  afforded  by  the  slit  lamp  is  sufficient,  and  therefore  the  Nernst 
slit  lamp  was  used  in  my  reflexless  ophthalmoscopes.  The  large 
ophthalmoscope  brought  on  the  market  by  Carl  Zeiss  contains  an 
aspheric  lens  not  only  in  the  examination  system,  but  also  in  the 
illuminating  system.  The  light  of  the  latter  is  reflected  into  the 
examined  eye  by  a  transparent  glass  prism  of  small  angle.  A  plate 
with  parallel  faces  would  give  two  different  images,  of  which  only 
one  could  be  used  if  the  plate  were  sufficiently  solid.  Therefore  the 
prism  is  so  calculated  that  both  images  coincide.  In  this  instrument 
the  Nernst  lamp  can  be  directly  replaced  by  a  nitra  lamp  or  by  a 
pointolite  lamp.  I  have  verified  that  the  latter  affords  a  sufficient 
illumination  though  the  lamp  be  mounted  along  the  axis  of  the 
illuminating  system,  and  although  only  a  part  of  the  optical  image  of 
the  glowing  ball  can  be  projected  in  a  part  of  the  slit. 

The  same  is  the  case  with  the  large  instrument  for  simplified  re- 
flexless ophthalmoscopy.  If  two  small  reflexes  caused  by  the  surfaces 
of  the  aspheric  lens  are  allowed,  the  construction  of  the  instrument  is 


78  ALLVAR  GULLSTRAND 

considerably  simplified  and  only  one  aspheric  lens  is  necessary.  The 
light  emerging  from  the  slit  is  given  the  appropriate  direction  by 
means  of  a  double  reflection  in  a  rectangular  prism  silvered  on  its 
hypotenuse  face  and  combined  with  a  decentrated  lens. 

For  this  method  of  ophthalmoscopy  I  also  have  devised  a  hand 
ophthalmoscope,  which  is  held  in  one  hand,  the  aspheric  lens  being 
held  in  the  other.  The  illuminating  system  is  a  slit  lamp  in  which  a 
small  incandescent  lamp  is  used  as  the  source  of  light.  Again  this 
instrument  demands  a  little  skill,  which  must  be  acquired  by  practice. 
Ordinary  ophthalmoscopy  by  the  indirect  method  should  be  replaced 
by  this  method  just  as  well  as  ordinary  ophthalmoscopy  by  the  direct 
method  is  to  be  replaced  by  simple  centric  ophthalmoscopy. 

CENTRIC  PHOTOGRAPHY  OF  THE  FUNDUS 

It  is  evident  that  the  same  principles  that  led  to  the  centric  reflex- 
less  ophthalmoscopy  are  applicable  theoretically  to  the  photography 
of  the  fundus.  In  practice  difficulties  arise  from  the  necessary  in- 
tensity of  light,  and  as  long  as  perfectly  aplanatic  condensers  of 
sufficient  size  and  aperture  are  not  available,  the  sun  is  the  only 
practicable  light  source.  But  if  an  optical  image  of  the  sun  is  pro- 
jected in  a  hole,  the  method  of  the  simplified  reflexless  ophthalmoscopy 
is  applicable  and  has  been  elaborated  by  Dr.  J.  W.  Nordenson,  who 
has  obtained  excellent  results  with  a  rather  compendious  apparatus. 
Thus  the  light  illuminating  the  fundus  for  photography  is  taken 
from  what  could  be  named  a  hole  lamp  with  the  sun  as  source  of  light. 

DISCUSSION 

DR.  EDWARD  JACKSON  (Denver,  Col.) :  The  name  of  Professor  Gullstrand 
is  universally  known  to  us,  but  it  will  have  a  new  significance  after  hearing 
the  address  he  has  given  us  this  morning.  We  are  especially  happy  in  having 
in  it  a  sort  of  summing  up  of  the  work  he  has  been  publishing  for  so  many 
years,  and  that  has  made  him  so  well  known  throughout  the  world.  He  has 
followed  the  normal  method  of  instruction,  starting  with  a  concrete  case  with 
the  slit  lamp,  and  now  bringing  before  us  the  general  principles  that  were  em- 
bodied in  that,  and  which  can  be  embodied  in  the  use  of  light  from  other 
sources,  the  whole  group  to  be  called  "diaphragm  lamps." 

Vision  depends  upon  getting  from  the  object  to  be  seen  a  sufficient  light,  as 
compared  with  the  light  received  from  sources  in  which  we  are  not  interested. 
We  are  just  beginning  to  realize  in  our  methods  of  examination  that,  if  we 
want  enough  light  from  the  structure  that  we  desire  to  examine,  we  must 
exclude  irrelevant  light  in  so  far  as  this  is  possible.  That  has  been  accom- 
plished best  by  the  slit  and  other  diaphragm  lamps.  The  conditions  of  dis- 


On  Diaphragm  Lamps  in  Ophthalmology  79 

tinct  vision  that  have  to  be  met — that  the  light  shall  be  bright  enough  (and 
external  light  is  worse  than  useless)  and  that  the  field  to  be  studied  shall  be 
uniformly  illuminated.  All  of  us  have  been  misled  for  an  instant  by  irregular 
illumination  into  thinking  that  we  had  some  retinal  or  choroidal  pathologic 
condition  that  was  not  present.  That  is  accurately  brought  out  by  the  use  of 
the  uniform  illumination. 

But  in  order  to  get  rid  of  the  light  that  we  do  not  want  we  must  have  sharp 
limits,  we  must  not  light  up  anything  except  the  structures  we  are  looking  at. 
That  is  obtained  with  the  diaphragm  lamp,  by  the  diaphragm  primarily,  and 
then  by  having  it  sharply  focussed  in  the  eye.  That  is  what  Professor  Gull- 
strand  has  worked  out.  First,  he  gave  us  enough  light  with  the  Nernst  slit 
lamp,  and  then  he  had  a  sharp  image  of  the  slit  formed  in  the  eye  where  the 
light  would  be  limited  to  a  certain  field. 

Of  course  that  can  be  done  with  the  hole  lamp,  but  I  cannot  help  but  feel 
that  the  slit  offers  certain  advantages.  As  he  has  pointed  out,  we  can  still 
have  the  slit  with  the  "hole  lamp."  This,  I  take  it,  is  the  idea  running  through 
the  focussing  apparatus  that  is  worked  out,  and  the  result  of  utilizing  the  dif- 
ferent methods  of  illumination.  I  have  been  interested  in  one  phase  of  illumi- 
nation, direct  sunlight,  and  hope  soon  to  call  attention  to  the  practical 
application  of  the  principles  that  have  been  put  before  us  by  Professor  Gull- 
strand  in  that  direction. 

DR.  HARRY  S.  GRADLE  (Chicago,  111.) :  It  might  be  of  interest  to  speak  of 
some  few  things  that  we  have  been  endeavoring  to  do  in  this  country.  The 
Pointolite  lamp  was  developed  in  England  in  1913,  and  has  been  used  rather 
extensively  by  microscopists  and  metallurgists,  and  in  this  country  in  micro- 
photography  with  great  success.  For  nearly  a  year  it  has  been  in  our  mind  to 
employ  the  Pointolite  with  the  apparatus  for  illumination  of  the  eye  for 
which  we  are  indebted  to  Professor  Gullstrand,  the  slit  lamp,  but  owing  to 
certain  difficulties  of  material  and  manufacture  it  has  been  impossible  until 
recently.  Now  we  have  a  large  tungsten  arc  in  a  low  pressure  gas  chamber, 
giving  as  nearly  a  punctate  source  of  light  as  possible.  This  may  be  used  in 
the  slit  lamp,  or  it  may  be  used  when  the  slit  is  replaced  by  the  diaphragm, 
resulting  in  a  more  nearly  true  focal  illumination  than  the  present  slit.  True 
it  is  that  the  slit  has  certain  advantages  for  both  direct  and  indirect  focal 
illumination,  but  there  are  areas  of  aberration  projected  by  the  slit  with  the 
Nitra  lamp  on  the  cornea  which  increase  as  we  narrow  the  slit  down  to  a 
minimum,  and  which  cannot  be  eliminated  owing  to  certain  mechanical 
difficulties.  I  believe  if  we  could  have  a  circular  aperture  with  the  Pointolite 
we  would  gain  a  great  deal. 

The  large  ophthalmoscope  of  Professor  Gullstrand,  unfortunately,  does 
not  add  any  to  the  clinical  examination  of  patients  in  any  but  the  very  excep- 
tional case,  but  to  the  ophthalmologist  who  takes  pleasure  in  clean-cut, 
scientific  work,  it  is  a  source  of  pleasure.  The  small  hand  ophthalmoscope 
of  Gullstrand,  which  we  have  been  using  for  eight  or  nine  years,  employs  a 
slightly  different  principle,  in  which  the  lower  portion  of  the  cornea  and  of  the 
pupil  is  illuminated  and  the  rays  returning  from  the  fundus  pass  out  through 
the  upper  portion  of  the  cornea,  which  is  without  any  illumination  whatever 


80  ALLVAR  GULLSTRAND 

and  consequently  is  reflex  free.  It  makes  indirect  ophthalmoscopy  much 
simpler  and  easier  than  by  the  older  methods  and  allows  us  to  study  the 
macula  without  the  corneal  reflexes  we  are  accustomed  to. 

DR.  E.  E.  BLAAUW  (Buffalo,  N.  Y.) :  On  the  question  of  the  slit  lamp  I 
think  the  Congress  stands  where  ophthalmology  stood  in  1851  when  the 
ophthalmoscope  was  introduced.  The  lamp  of  Professor  Gullstrand  has  given 
us  a  field  of  light  so  enormous  that  those  who  have  not  used  the  corneal  micro- 
scope cannot  appreciate  what  it  means  to  us  as  ophthalmologists.  But  one 
should  not  say  that  its  use  is  easy,  for  it  takes  hours  and  hours  of  study.  We 
must  be  able  to  narrow  the  slit,  because  a  slit  that  cannot  be  opened  and 
closed  is  of  no  value.  It  is  still  difficult  to  interpret  what  we  see  with  the  slit 
lamp.  Of  enormous  value  is  the  appreciation  of  depth,  for  it  enables  us  to  see 
changes  that  have  not  been  known  before,  and  it  shows  us  that  we  have  no 
way  of  attacking  the  vitreous  unless  we  do  it  in  vivo. 

PROFESSOR  G.  F.  ROCHAT  (Groningen,  Holland):  I  have  no  doubt 
that  the  new  instrument  that  Professor  Gullstrand  has  spoken  of  will  be  a 
much  more  beautiful  instrument  than  his  former  one,  but  I  think  the  slit 
lamp  in  its  previous  form  has  one  special  advantage  over  the  new  lamp  he 
has  described,  and  that  is  this:  When  we  throw  a  beam  of  light  into  the 
cornea,  its  intersection  with  the  cornea  is  a  rectangular  prism,  of  which  the 
anterior  surface  coincides  with  the  anterior  surface  of  the  cornea,  while  its 
lateral  side  shows  a  definite  rectangular  and  plane  section  of  the  cornea,  and 
in  this  luminous  section  you  can  observe  and  localize  particles  present  as 
clearly  as  in  microscopic  section.  I  am  afraid  that  in  the  new  form,  in  which 
the  intersection  of  the  cornea  and  beam  of  light  is  not  plane,  but  cylindrical, 
this  advantage  will  have  been  lost.  I  shall  be  glad  to  have  Professor  Gull- 
strand's  opinion  on  that. 

PROFESSOR  ALLVAR  GULLSTRAND  (closing) :  I  am  surprised  that  so  many  of 
my  American  colleagues  have  devoted  so  much  time  to  the  study  of  my  meth- 
ods, and  I  want  to  thank  those  who  have  taken  part  in  the  discussion.  Dr. 
Jackson  has  pointed  out  that  you  can  get  a  good  result  with  direct  sunlight, 
and  if  I  understood  him  aright  he  is  operating  with  direct  sunlight.  I  hope 
that  the  photographs  that  Dr.  Nordenson  will  show  tomorrow  will  prove  that 
Dr.  Jackson  is  right  in  trying  sunlight.  But  I  hope  that  the  Pointolite  lamp 
will  be  shown  to  be  sufficient  for  most  purposes. 

Dr.  Gradle  spoke  of  the  scientific  work  that  can  be  done  with  the  slit  lamp, 
and  he  as  well  as  Dr.  Blaauw  questioned  the  necessity  of  having  a  slit  for 
localization  in  opacities,  or  in  pathologic  signs,  as  to  the  dimensions.  We  now 
have  a  beam  of  light  that  is  not  too  wide.  I  think  the  Pointolite  is  the  best 
in  practical  work. 


SINTOMAS  OCULARES  DEL  ENVENENAMIENTO 
FOR  EL  PIQUETE  DE  ALACRAN1 

DR.  JOSE  DE  JESUS  GONZALEZ 
De  Leon,  Gto.,  Mexico 

En  la  invitacion  dirigida  por  la  Comision  General  de  Organizacion 
del  Congreso  Internacional  de  Oftalmologia,  que  se  reunira  en  Wash- 
ington, indicase  que  "son  apropiados  a  los  fines  del  Congreso  los 
trabajos  que  se  refieran  a  enfermedades  o  fases  de  enfermedades, 
peculiares  a  los  distintos  paises  o  regiones." 

Esta  indicacion  me  hace  dar  a  conocer  los  sintomas  oculares  que  he 
observado  en  personas  que  han  sufrido  el  piquete  del  alacrdn,  algunos 
de  los  cuales  sintomas,  por  persistir  cuando  todo  otro  sintoma  de 
envenenamiento  ha  desaparecido  y  aun  revestir  cierta  gravedad,  son 
interesantes  de  conocer  por  todo  oculista  que  ejerza  en  las  regiones 
infestadas  por  los  escorpionideos. 

Ademas,  desde  el  punto  de  vista  puramente  cientifico,  algunos  de 
los  smtomas  oculares  son  altamente  interesantes,  porque  contribuyen 
a  precisar  la  accion  de  la  ponzoria  del  alacrdn. 

Para  la  mejor  inteligencia  del  asunto,  divide  este  pequeno  estudio 
en  tres  partes : 

I.  Algunos  datos  sobre  los  alacranes  de  Mexico. 

II.  Sintomatologia  general  del  envenenamiento  por  el  piquete  de 
alacrdn. 

III.  Sfntomas  y  complicaciones  oculares  de  dicho  envenenamiento. 

I.  ALGUNOS  DATOS  SOBRE  LOS  ALACRANES  DE  MEXICO 
Los  alacranes  o  escorpiones  son  artropodos,  pertenecientes  a  la  clase 

de  los  ardcnidos  y  al  orden  de  los  escorpiones,  orden  que  comprende  de 

350  a  400  especies  diseminadas  por  todo  el  mundo. 
En  la  Republica  Mexicana,  segun  la  Biologia  Centrali  Americana, 

citada  por  el  Sr.  Moises  Herrera,2  unicamente  viven  dos  especies  de  la 

1  Estudio  presentado  al  Congreso  International  de  Oftalmologia  que  se  reunird 
en  Washington,  E.U.A.,  en  Abril  de  1922. 

2  Moises  Herrera,  Naturalista  de  la  Direcci6n  de  estudios  biolog. — Los  escor- 
piones de  Mexico.  Mem.  de  la  Soc.  Cientifica,  "Antonio  Alzate,"  Tomo39,  Mexico, 
1921. 

6  81 


82  JOSE  DE  JESUS  GONZALEZ 

familia  scorpionidae:  el  diplocentrus  whitei  (o  diplocentrus  mexicanus) 
y  el  diplocentrus  keyserlingi,  Karsch. 

Pero  el  distinguido  Profesor  Isaac  Ochoterena1  recuerda  que  en  la 
magistral  obra  Das  Tierreich  (8.  Lieferung.  Arachnoidea.  1899) 
los  escorpionideos  se  dividen  en  seis  familias,  la  primera  de  las  cuales, 
la  de  los  Bothruridae,  comprende  las  familias  Centrurinae,  con  los 
ge"neros  Centrums,  Isometrus,  Zabius  y  Tytius. 

Los  alacranes  del  genero  Centrums  (Hemprich  u.  Ehrenberg) 
comprende  14  especies,  de  las  cuales  se  encuentran  en  la  Repiiblica 
Mexicana  las  siguientes:  Centrurus  infamatus,  C.  L.  Koch,  Centrurus 
gracilis,  Latr.,  Centrurus  margaritatus,  Gerv.,  Centrurus  infamatus, 
var.  nigrovariegata,  Poc.,  Centrurus  nigrimanus,  Centrurus  fulvices, 
Poc.,  Centrurus  flavopictus,  Poc.,  Centrurus  ochraceus,  Poc.,  Centrurus 
nitidus,  Thor. 

Uno  de  los  alacranes  mds  venenosos  del  pais,  el  conocido  con  el 
nofnbre  de  alacrdn  de  Durango,  (y  que  no  es  exclusive  de  esa  ciudad, 
pues,  segiin  el  Dr.  Mariano  Herrera,2  existe  en  todo  el  Sur  del  pais, 
especialmente  en  las  vertientes  de  la  Sierra  Madre)  que  ha  sido  bien 
estudiado  por  el  Sr.  Prof.  I.  Ochoterena,  pertenece  a  la  especie  Cen- 
trurus exilicauda,  descrito  por  Wood. 

En  la  ciudad  de  Leon,  Gto., — en  donde  ejerzo  desde  hace  25  afios, 
hay  dos  especies :  una,  poco  venenosa,  de  color  moreno  obscuro  (diplo- 
centrus mexicanus?),  y  otra  muy  venenosa,  de  color  amarillento, 
que  tiene  gran  semejanza  con  el  Centrurus  exilicauda,  de  Durango. 
He  oido  decir  a  medicos  que  tienen  muchos  afios  de  ejercer  en  la 
ciudad,  que  antes  no  observaban  accidentes  series  con  el  piquete  del 
alacran,  lo  que  me  hace  suponer  que  tal  vez  ha  sido  importado  el 
alacrdn  venenoso  de  Durango,  oculjto  entre  las  pieles  sin  curtir  que  la 
industria  peletera  de  la  ciudad  hace  venir  de  las  regiones  del  norte  del 
pais,  entre  ellas  de  donde  abunda  el  escorpionideo. 

Aunque  suele  encontrarse  el  alacran  durante  todo  el  ano,  los  meses 
en  que  mds  abunda  en  esta  ciudad,  sin  duda  por  ser  su  temperatura 
media  mds  favorable  al  ardcnido,  son  los  de  marzo,  abril,  mayo  y 
junio,  durante  los  cuales,  ademds,  parece  ser  mds  activa  la  ponzona, 
pues  los  accidentes  que  he  observado  entonces  son  mds  series.  Igual 

1  Prof.   Isaac  Ochoterena.     El  alacrdn   de   Durango    (Centrurus  exilicauda, 
Wood).     Memorias  y  Revista  de  la  Sociedad  Cientifica  "Antonio  Alzate, "  Tomo 
37,  nums.  4.  5  y  6,  Mexico,  1920. 

2  Dr.    Mariano    Herrera.     Estudio    sobre    el    piquete    de    alacran.     Revista 
Medica,  Tomo  XIII,  num.  1.  Mexico,  1900. 


Sintomas  Ocular  es  del  Envenenamiento  por  el  Piquete  de  A  lacrdn    83 

cosa  pasa  en  Durango,  segun  el  Dr.  Mariano  Herrera,  quien  textual- 
mente  dice :  "  casi  exclusivamente  se  observa  a  fines  de  abril,  en  mayo 
y  en  junio,  terminando  con  los  primeros  aguaceros  formales  que  se 
verifican  en  julio."  Y  agrega:  "no  porque  no  pueda  haber  acci- 
dentes  en  otras  epocas  del  ano,  como  se  ve  en  los  cuadros  de  mor- 
talidad,  sino  porque  tales  accidentes  tienen  el  caracter  de  excep- 
cionales."  (Loco  citato.)  La  temperatura  media  de  esos  meses 
escila  entre  19°  y  25°. 

El  aparato  venenoso  consta  de  dos  gldndulas,  colocadas  a  uno  y 
otro  lado  del  ultimo  segmento  del  post-abdomen.  Cada  gldndula 
estd  constituida  por  un  tejido  conjuntivo  periglandular,  muy  delicado, 
una  gruesa  capa  de  tejido  muscular,  cuya  contraccion  expulsa  el 
veneno,  y  el  epitelio  glandular  con  numerosas  invaginaciones,  capa 
propiamente  secretante.  De  cada  glandula  parte  un  canal  eferente 
que  va  a  desembocar  cerca  de  la  extremidad  del  aguijon,  que  es  curvo, 
muy  duro,  acerado  y  terminado  por  una  punta  roja.  (Ochoterena.) 

El  veneno  es  liquido,  transparente,  de  reaction  acida,  propiedades 
que  he  observado  personalmente.  El  Dr.  Mariano  Herrera  cree  que 
es  de  naturaleza  oleoginosa,  pues  haciendo  picar  a  un  alacrdn  sobre 
un  papel  delgado,  se  obtiene  una  pequena  mancha  translucida  y 
persistente,  analoga  a  la  que  deja  un  liquido  aceitoso.  El  Prof. 
Ochoterena  dice  que  se  altera  rdpidamente  al  contacto  del  aire,  que, 
disuelto  en  agua,  se  vuelve  opalescente  con  irisaciones  azuladas  y  en 
parte  precipita  (globulinas),  produciendo  espuma  si  se  agita.  El 
alcohol,  el  yodo,  el  amoniaco,  el  tanino,  el  nitrato  de  plata,  el  acetato 
de  plomo  y  el  sulfato  de  amoniaco,  lo  precipitan  de  sus  disoluciones  y 
el  producto  de  la  evaporation  en  el  vacio  esta  formado  de  laminillas 
de  color  amarillo  obscuro. 

Parece  que  esta  ponzona  es  una  toxi-albumina  especial  (Calmette) . 
Su  actividad  es  extraordinaria,  pues  la  cantidad  introducida  por  un 
piquete,  es  muy  pequena:  inmediatamente  despues  de  producida 
en  mi  mismo  una  picadura  en  un  dedo,  he  podido  extraer,  por  expre- 
sion  fuerte,  una  pequena  gota  de  poco  mds  de  un  milimetro  de  did- 
metro. 

La  manera  de  obrar  la  ponzona,  nos  la  va  a  decir  el  cuadro  sinto- 
mdtico  desarrollado  a  consecuencia  del  piquete  de  alacrdn. 


84  JOSE  DE  JESUS  GONZALEZ 

II.  SlNTOMATOLOGIA  GENERAL  DEL  ENVENENAMIENTO  FOR  EL 
PIQUETE  DE  ALACRAN 

Para  que  sirva  de  punto  de  comparacion  a  los  observadores  de 
otras  regiones,  voy  a  desarrollar  el  cuadro  del  envenenamiento  por 
la  ponzona  de  alacran,  basado  exclusivamente  en  lo  que  he  observado 
personalmente. 

El  piquete  produce  la  sensacion  de  una  delgada  aguja  que  rdpida- 
mente  se  hundiera  en  la  piel;  pero  esta  dolorosa  sensacion — que  he 
experimentado  en  mi  mismo — desaparece  casi  inmediatamente  y 
por  algunos  minutos  se  cree  que  nada  va  a  pasar.  Y  en  efecto:  si 
se  exprime  inmediatamente  el  punto  picado,  sale  una  pequena  gota  del 
liquido  venenoso,  y  no  se  produce  ningiin  otro  sintoma,  ni  local  ni 
general.  Para  facilitar  la  expresion  del  veneno,  es  conveniente  prac- 
ticar  una  pequena  incision  de  la  piel;  desgraciadamente  es  raro  que 
esta  pequena  operacion  se  haga  oportunamente. 

Entonces  se  deja  que  el  veneno  se  absorba,  para  lo  cual  sigue  dos 
caminos:  el  de  los  capilares  linfaticos  y  el  de  los  capilares  sanguineos. 
Pocos  minutos  despues  comienza  una  sensacion  de  hormigueo  en  las 
partes  cercanas  al  piquete  y  pronto  esa  penosa  sensacion  se  generaliza, 
siendo  uno  de  los  sintomas  que  mas  torturan  al  enfermo.  Algunos 
de  ellos  me  han  comparado  ese  hormigueo  al  que  se  sufre  cuando 
empieza  a  volver  la  sensibilidad  a  un  pie  que  se  ha  adormicido  por  la 
compresion  del  ciatico.  Otros  dicen  que  son  finas  y  repetidas  cor- 
rientes  electricas  que  circularan  por  todo  el  cuerpo,  inclusive  por  las 
visceras  abdominales:  un  enfermo  permanecia  inmovil,  rogando  que 
no  se  le  tocara,  porque  una  corriente  electrica  parecia  atravesarle  los 
intestines. 

En  la  cara,  principalmente  en  los  pdrpados  y  en  las  alas  de  la  nariz, 
experimentase  un  cosquilleo  insoportable,  que  origina  penosos  y 
frecuentes  estornudos. 

Al  lado  de  estas  parestesias  cutdneas,  senalare  uno  de  los  sintomas 
mas  frecuentes  y  mas  precoces :  la  sensacion  de  una  marana  de  cabellos 
en  la  lengua  y  en  la  garganta.  Si  se  permite  la  extension  del  termino, 
dire*  que  es  esta  una  parestesia  mucosa,  ya  que  parestesia  es  toda  sensa- 
cion subjetiva  anormal. 

Tambien  existen  perturbaciones  objetivas  de  la  sensibilida:  la 
hiperestesia  es  intensa;  cualquier  contacto,  el  mas  ligero  frotamiento, 
causan  al  enfermo  sensaciones  dolorosas  o  de  quemadura  y  aun 
despiertan  intensos  reflejos  cutdneos  o  musculares. 


Sintomas  Ocular  es  del  Envenenamiento  por  el  Piquete  de  A  lacrdn    85 

Creo  que  debe  atribuirse  a  la  hiperestesia  de  la  mano  y  de  los  dedos 
una  perturbation  de  la  perception  ester  eognostica:  los  enfermos  re- 
conocen  bien  todos  los  objetos  por  el  tacto;  pero  les  conceden  dimen- 
siones  mayores  a  las  reales.  Podrfa  designarse  esta  perturbation  con 
el  neologismo  de  disestereognosia  o,  haciendo  una  contraction:  dis- 
tereogosia. 

Simultaneamente  con  las  perturbaciones  sensitivas,  desarrollanse 
otras  secretoras  y  matrices. 

Entre  las  secretoras,  la  hipersecrecion  saliver,  de  una  saliva  glutinosa 
y  espesa,  y  de  las  mucosas  nasal,  faringea  y  bronquica,  sonstituye  uno 
de  los  sintomas  mas  precoces,  que  indica  que  la  ponzona  se  ha  generali- 
zado  y  van  a  empezar  los  fenomenos  convulsivos  de  que  luego  hablare. 
El  enfermo  se  ve  obligado  a  estar  continuamente  escupiendo  y  ex- 
pectorando,  sin  conseguir  amenguar  la  penosa  sensation  de  cabellos 
que  se  le  enredaran  en  la  garganta. 

Senalare  en  este  lugar,  por  tratarse  de  una  perturbation  secretora, 
aunque  el  sintoma  se  presente  mas  tarde,  la  hipersecrecion,  de  sudor 
que  es  abundantisma :  toda  la  piel  del  enfermo  esta  constantemente 
bafiada  en  sudor.  Tal  parece  que  el  organismo  escoge  por  vias  de 
elimination  del  veneno,  el  sudor,  la  saliva  y  las  secreciones  naso- 
f  ar  ingo-br  onquicas . 

Son  las  perturbaciones  matrices  las  mas  penosas  y  las  que  ponen  mas 
en  peligro  la  vida  del  enfermo.  Se  presentan  pocos  minutos  despues 
de  que  el  hormigueo  se  ha  generalizado  y  consisten  en  espasmos  de  los 
musculos  lisos  y  convulsiones  y  contracturas  de  los  voluntaries. 

Los  espasmos  empiezan  por  la  faringe  y  el  esofago:  los  enfermos, 
atormentados  por  la  sed,  se  sorprenden  de  que  no  pueden  pasar  el 
agua  o  lo  hacen  con  suma  dificultad.  Los  espasmos  del  estomago 
producen  vomitos,  primero  alimenticios  y  luego  mucosos.  Aunque 
raros,  hay  casos  en  que  contrayendose  el  estomago  en  vacio,  se  pro- 
ducen homorragias  y  hematemesis  de  cierta  gravedad.  Los  espasmos 
del  intestino  dan  a  los  enfermos  la  penosasima  sensation  de  que  una 
corriente  electrica  atraviesa  todos  los  organos  abdominales.  El 
espasmo  del  cuello  vesical  origina  retention  de  orina,  la  que,  por  otra 
parte,  es  escasa,  probablemente  por  la  abundante  sudacion.  Los 
espasmos  de  los  musculos  bronquicos  contribuyen  sin  duda  a  aumen- 
tar  los  fenomenos  asfixicos  de  que  pronto  hablare. 

Las  contracturas  se  presentan  principalmente  en  los  maseteros, 
originando  un  trismus  que  dificulta  la  ministration  de  medicamentos 
por  ore. 


86  JOSE  DE  JESUS  GONZALEZ 

Las  convulsiones  pronto  se  generalizan  y  agitan  contorcionan  todo 
el  cuerpo.  Son  de  caracter  tonico,  a  veces  los  miisculos  se  tetanizan 
y  cuando  el  tetanismo  invade  los  miisculos  respiratorios,  se  presenta 
la  asfixia,  exagerada  por  la  abundante  hipersecrecion  bronquica  y  los 
espasmos  de  los  musculos  lisos  de  la  par  red  del  arbol  aereo.  En  los 
ninos  estos  accidentes  son  a  menudo  mortales:  la  respiration  es 
estertorosa  y  superficial,  los  labios  se  cianosan,  por  la  boca  salen 
mucosidades  espumosas,  frecuentes  accesos  de  tos  convulsiva  inter- 
rumpe  y  agrava  el  tetanismo  de  los  musculos  respiratorios,  un  sudor 
frio  empapa  los  cabellos  del  nino  y  corre  por  el  cuerpo,  y  el  pequenuelo 
cae  en  un  estado  semicomatoso  en  el  que  a  veces  sucumbe.  Pocas 
veces  en  el  adulto  llega  la  gravedad  a  tal  extreme,  aunque  tambien 
hay  casos  mortales. 

En  el  niiio  he  observado  convulsiones  del  diafragma  y  de  otros 
musculos  respiratorios  que  se  traducen  por  un  llanto  espasmodico, 
tan  caracteristico,  que  en  dos  ocasiones,  con  solo  oir  de  lejos  ese  llanto 
en  ninos  que  eran  conducidos  a  mi  consultorio,  pude  hacer  el  diag- 
nostico  de  piquete  de  alacrdn,  luego  confirmado  por  los  padres  del 
pequeno. 

En  el  adulto,  en  los  mementos  de  mayor  intensidad  del  envene- 
namiento,  las  convulsiones  tonicas  agitan  y  contorsionan  los  brazos 
y  las  piernas,  las  mucosidades  excitan  la  laringe  y  producen  accesos 
de  tos  y  expectoration,  el  tialismo  es  abundante,  un  sudor  copioso 
empapa  todo  el  cuerpo,  la  temperatura  se  eleva  hasta  40°  y  41° — 
tanto  por  el  exceso  de  trabajo  muscular,  como  por  action  de  la  pon- 
zona  sobre  los  centres  termogenos,  pues  a  veces  las  convulsiones  son 
poco  intensas  y  sin  embargo  la  temperatura  asciende-,  el  enfermo 
siente  un  calor  sofocante  y,  presa  de  grande  inquietud,  no  encuentra 
sitio  en  su  lecho  para  reposar  un  instante,  y  grita  y  gesticula  y  se 
retuerce.  El  pulso  es  frecuente. 

La  cara  estd  congestionada  y  edematosa. 

La  palabra  es  ininteligible :  el  trismus,  las  contracciones  de  los 
musculos  de  la  lengua,  la  abundancia  de  saliva  y  de  mucosidades,  la 
horrible  sensation  de  la  marafia  de  cabelles,  son  todas  circunstancias 
capaces  de  hacer  la  palabra  tartajosa  e  ininteligible. 

Por  regla  general,  la  inteligencia  se  conserva,  en  medio  de  aquel 
cuadro  intensamente  dramatico:  el  enfermo  entiende  nuestras  pre- 
guntas  y  contesta  a  ellas  con  acierto.  Pero  aun  entonces  el  psiquismo 
no  es  enteramente  normal:  la  atencion,  prisionera  del  intense  malestar, 
no  puede  fijarse  en  nada;  las  emociones  exaltativas,  sobre  todo  la 


Sintomas  Oculares  del  Envenenamiento  por  el  Piquete  de  Alacrdn     87 

ira,  contribuyen  a  aumentar  la  exaltacion  del  enfermo;  la  memoria 
es  torpe.  Pero  no  hay  alucinaciones,  ni  ilusiones,  ni  delirio.  Solo 
en  los  casos  graves  y  fatales,  el  enfermo  cae  en  un  estado  de  estupor  y 
de  inconciencia,  precursor  de  la  muerte. 

Todo  este  periodo,  que  debe  llamarse  conjusticia,  de  excitation,  es 
variable  en  intensidad  y  en  duracion,  segun  diversas  circunstancias : 
edad  de  la  persona  picada,  sexo,  epoca  del  ano,  cantidad  de  ponzona 
inyectada;  pues  los  ninos,  los  ancianos  y  las  mujeres  son  mas  sucep- 
tibles,  los  meses  de  marzo  a  junio,  los  de  mayor  actividad  del  aracnido, 
y  las  horas  que  siguen  al  crepiisculo  las  mds  peligrosas,  antes  de  que 
el  alacrdn  haya  tenido  tiempo  de  picar  otres  objetos — insectos,  etc. — 
y,  por  lo  mismo,  antes  de  que  haya  vaciado  en  parte  sus  glandulas. 

El  periodo  de  excitation  dura  de  12  a  24  horas  y  los  smtomas  se  van 
poco  a  poco  atenuando  y  disminuyendo  la  gravedad  de  la  situacion. 

Pero  al  periodo  primero  sigue  otro  periodo  de  depresion:  a  las  con- 
vulsiones,  suceden  la  torpeza  en  los  movimientos,  los  temblores,  la 
ataxia  y  aun  verdaderas  paralisis,  que  suelen  durar  unos  dias:  he 
visto  un  enfermo  que  conserve  por  una  semana  cierta  incoordinacion 
motriz,  otro  que  sufrio  una  paraplejia,  una  pobre  anciana  que  quedo 
con  una  paralisis  de  la  vejiga  que  no  llego  a  ceder,  pues  exigiendo  el 
frecuente  sondeo,  acabo  por  infectarse  la  vejiga  y  producirse  una 
cistitis  mortal. 

A  los  hormigueos  del  principle,  siguen  sensaciones  de  adorme- 
cimiento,  sobre  todo  en  las  extremidades ;  es  decir :  a  las  parestesias 
de  excitation  suceden  parestesias  de  depresion. 

Todavia  dias  despues,  la  deglucion  se  hace  con  dificultad,  pero  no 
ya  por  espasmo,  sino  por  paresia  faringea. 

Condensando  en  una  dasificacion  todos  los  smtomas  observados, 
tenemos : 

Sintomas  sensitivos:  dolor,  en  el  lugar  de  la  inyeccion,  parestesias 
(hormigueos,  cosquilleos,  sensacion  de  marana  de  cabellos),  hiperes- 
tesias. 

Sintomas  secretorios:  hipersecrecion  de  las  gldndulas  salivares, 
mucosas  de  la  nariz,  faringe  y  broquios,  glandulas  sudoriparas. 

Sintomas  vaso-motores:  vaso-dilatacion  de  los  vasos  de  la  piel  de  la 
cara,  de  la  mucosa  nasal,  de  la  conjuntiva;  edema  de  la  cara. 

Sintomas  termicos:  hipertermia  en  el  periodo  de  excitacion;  hipo- 
termia  en  los  casos  fatales. 

Sintomas  motores:  En  el  periodo  de  excitacion,  espasmos  de  los 
miisculls  lisos;  contracturas  y  convulsiones  de  los  rmisculos  estriados. 


88  JOSE  DE  JESUS  GONZALEZ 

En  el  periodo  de  depresion :  musculos  lisos,  paresias;  musculos  estria- 
dos,  temblores,  ataxia,  pardlisis. 

Reflejos:  periodo  de  excitacion,  exagerados;  periodo  de  depresion, 
normales. 

Se  ha  dicho  que  mientras  el  veneno  de  la  serpiente  es  neurotoxico, 
el  del  alacran  es  miotoxico.  El  analisis  cuidadoso  de  los  sintomas  que 
acabo  de  describir,  nos  inclinaran  mas  bien  a  considerar  la  ponzofia 
del  alacran  como  neurotoxica,  llevando  su  accion  excitante  sobre  la 
medula  (exageracion  de  los  reflejios,  fenomenos  motores,  fenomenos 
sensitives),  sobre  el  simpatico  (vaso-dilatacion,  edema,  espasmos  de 
los  musculos  lisos,  taquicardia,  hipertermia,  hipersecrecion)  y  aun 
sobre  los  cordones  nerviosos  mismos,  como  parecen  demostrarlo 
algunas  complicaciones  oculares  que  luego  describire. 

A  proposito  de  la  hipersecrecion  salivar,  debo  recordar  algunos  datos 
recientes  sobre  la  fisiologia  del  simpatico :  las  gldndulas  submaxilares 
y  sublingual,  que  son  las  directamente  influenciadas  con  la  excitacion 
del  simpatico  cervical,  producen  una  saliva  viscosa,  es  decir,  exacta- 
mente  igual  a  la  que  se  produce  en  los  emponzofiados  con  el  piquete 
de  alacrdn.  Las  parotidas,  cuya  saliva  es  espumosa  y  m£s  fluida, 
no  son  directamente  influenciadas  por  la  excitacion  del  simpatico. 
Estos  datos  hablan  en  favor  de  la  accion  excitante,  sobre  el  simpatico, 
del  veneno  del  alacran. 

El  veneno  del  alacrdn  es,  pues,  neurotoxico  excitante;  los  fenomenos 
de  depresion  que  se  encuentran  despues  que  cesaron  los  fenomenos 
tormentosos,  pueden  ser  atribuidos  a  agotamiento  de  la  celdilla  ner- 
viosa,  que  ha  hecho  tan  fuertes  gastos  de  energia. 

No  quiero  terminar  sin  decir  dos  palabras  sobre  terapeutica.  Mien- 
tras no  poseamos  un  suero  especifico  como  el  anti-cobraico,  como  el 
anti-crotalico,  nos  veremos  reducidos  a  dos  medios  curatives:  uno, 
la  eliminacion  del  veneno;  otro,  la  medicacion  sintomdtica.  Para 
eliminar  el  veneno,  tenemos  que  recurrir  a  las  vias  indicadas  por  la 
naturaleza:  el  sudor  y  la  saliva.  El  medicamento  indicado  es  la 
pilocarpina,  en  inyecciones  hipodermicas,  vigilando  su  empleo:  en 
mis  manos  ha  sido  muy  eficaz.  La  medicacion  sintomdtica  debe 
dirigirse  principalmente  contra  el  sintoma  mds  peligroso :  los  espasmos 
respiratorios.  Las  inhalaciones  de  cloroformo,  hechas  con  la  mayor 
prudencia,  nos  dardn  tiempo  para  esperar  la  eliminacion  del  veneno, 
unico  medio  de  salvar  la  vida  del  enfermo. 


Slntomas  Oculares  del  Envenenamiento  por  el  Piquete  de  A  lacrdn     89 

III.  SlNTOMAS  Y  COMPLICACIONES  OCULABES  DEL  ENVENENAMIENTO 
POR  EL  PIQUETE  DE  ALACRAN 

Durante  el  periodo  de  excitacion,  en  medio  de  la  situacion  tan 
dramatica  y  ante  la  gravedad  del  pronostico  quoad  vitam,  los  sintomas 
oculares  ocupan.un  segundo  lugar  ante  la  atencion  del  medico,  aunque 
a  veces  molestan  mucho  a  los  enfermos;  pero,  pasados  los  mementos 
de  peligro  y  de  angustia,  las  manifestaciones  oculares  del  envenena- 
miento  empiezan  a  ocupar  un  lugar  preponderante  y,  en  ocasiones, 
llegan  a  constituir  verdaderas  complicaciones  que,  habiendo  desapa- 
recido  todo  otro  sintoma,  son  ellas  la  unica  enfermedad.  Salta  a  la 
vista  la  importancia  que  entonces  alcanzan  para  el  oftalmologista. 

En  el  primer  periodo  del  envenenamiento — periodo  que  he  llamado 
de  excitacion — los  sintomas  que  se  presentan  del  lado  de  los  ojos  son 
de  toda  clase:  sensitives,  secretorios,  vaso-motores,  motores  y  sen- 
soriales.  Los  senalare  en  este  orden. 

Perturbaciones  sensitivas. — Una  de  las  regiones  en  que  son  mas 
intensas  las  parestesias  que  he  senalado,  es  en  la  ocular :  los  parpados 
y  la  conjuntiva  son  el  sitio  de  hormigueos  y  cosquilleos  molestisimos, 
que  obligan  a  los  enfermos  a  frotarse  continuamente  los  ojos,  cuando 
menos  al  principio,  antes  de  que  las  intensas  convulsiones  les  impidan 
hacerlo. 

Perturbaciones  secretoras. — A  la  vez  que  las  hipersecreciones  nes  de 
que  he  hablado,  se  establece  un  abundante  lagrimeo.  Precisa  re- 
cordar  que  si  la  secrecion  lacrimal  es  principalmente  producida  por  la 
accion  de  las  fibras  organicas  del  sistema  craneal  (para-simpatico 
craneal),  tambien  la  provoca  la  excitacion  del  simpatico  cervical;  la 
hipersecrecion  salivar  viscosa,  como  la  que  produce  la  excitacion  del 
simpatico  cervical,  me  hacen  pensar  que  tambien  el  lagrimeo  esta 
bajo  la  dependencia  de  la  excitacion  de  esta  parte  del  simpatico,  aun- 
que no  se  limita  a  ella  la  accion  de  la  ponzona,  como  lo  indican  sin- 
tomas tales  como  los  espasmos  intestinales  y  la  contractura  del 
esfinter  del  cuello  vesical,  que  se  deben  a  la  excitacion  de  la  cadena 
lateral  lombar,  para  no  citar  otros. 

Perturbaciones  vaso-motrices. — Dos  fenomenos  de  este  orden  pode- 
mos  senalar :  la  hiperemia  de  la  conjuntiva  y  el  edema  de  los  parpados. 
Es  muy  dificil  explicar  la  vaso-dilatacion  de  los  tegumentos  de  la  cara 
y  de  las  mucosas,  que  es  un  sintoma  de  interruption  del  simpatico 
cervical,  al  lado  de  otros  sintomas  de  excitacion,  como  las  hiper- 
secreciones lacrimal,  salivar,  sudoral.  ^Se  trata  de  accion  directa  de 


90  JOSE  DE  JESUS  GONZALEZ 

la  ponzona  del  alacrdn  sobre  las  fibras  musculares  de  la  pared  vascu- 
lar? O  bien  la  intensa  actividad  glandular  en  la  piel  y  las  mucosas, 
provocada  por  la  excitacion  del  simpatico,  tendrd,  como  consecuencia 
la  produccion  de  metabolites — segun  la  teoria  de  Gaskell — que  ten- 
drfan  una  accion  vaso-dilatadora?  No  puedo  hacer  mas  que  emitir 
estas  hip6tesis. 

Perturbaciones  matrices. — Producense  tanto  en  los  musculos  ex- 
trfnsecos,  como  en  los  intrisecos  del  ojo.  En  el  perfodo  de  excitacion 
— que  es  el  que  describe  en  este  momento — he  observado  variados 
estrabismos,  predominando  el  convergente,  debidos  a  contracturas  de 
los  musculos  oculo-motores. 

Del  lado  de  la  musculatura  intriseca,  el  sintoma  mas  constante  es 
la  miosis.  Habiendo  otros  sintomas  de  excitacion  del  simpatico,  la 
miosis  no  podria  ser  atribuida  a  la  paralisis  de  este  sistema,  tanto  mds 
cuanto  hay  fenomenos  de  excitacion  del  motor  ocular  comun — que 
acabo  de  senalar — y  que  explican  perfectamente  la  miosis  por  con- 
traccion  del  esfinter.  Para  precisar  mejor  esto,  he  recurrido,  como 
medio  de  diagnostico,  a  las  instilaciones  de  solucion  de  cocaina:  re- 
cue"rdese  que  en  la  miosis  por  paralisis  del  simpdtico  (paralisis  de  las 
fibras  dilatadoras  de  la  pupila)  la  instilacion  de  cocaina  produce 
midriasis,  mientras  que  queda  sin  efecto  en  la  miosis  por  excitdcion 
del  motor  ocular  comun  (contraccion  del  esfinter  pupilar).  Esto 
ultimo  pasa  en  la  miosis  de  los  emponzonados  por  el  veneno  del 
alacrdn. 

A  la  miosis  acompanan  espasmos  de  la  acomodacion  que,  provo- 
cando  miopia  acentuada,  son  una  de  las  causas  de  la  perturbacion  de 
la  vista  y  tal  vez  de  la  micropsia  de  que  se  que j  an  algunos  enfermos. 

Perturbaciones  sensoriales. — Quejanse  los  enfermos  de  que  una 
niebla  envuelve  todos  los  objetos  y  de  que  las  luces  estdn  rodeadas  de 
circulos  irisados;  estos  sintomas  y  la  fotofobia,  que  casi  nunca  falta, 
podrfan  ser  atribufdos  a  la  accion  de  la  ponzona  sobre  la  retina,  direc- 
tamente,  como  parecen  demostrarlo  algunas  observaciones,  o  a  la 
congestion  retiniana  que  probablemente  se  encuentra,  ya  que  la  vaso- 
dilatacion  se  extiende  a  todos  los  vases  cutdneos  y  mucosos,  pero  que 
no  he  podido  comprobar  al  oftalmoscopio,  por  impedirmelo  la  miosis 
y  la  agitacion  motriz  del  enfermo. 

La  diplopfa,  causada  por  el  estrabismo  y  la  micropsia,  seguramente 
consecutiva  al  espasmo  de  la  acomodacion,  son  nuevos  factores  que 
contribuyen  a  la  produccion  de  las  perturbaciones  visuales. 

Por  regla  general,  todos  estos  smtomas  van  atenudndose  a  la  vez 


Sintomas  Oculares  del  Envenenamiento  por  el  Piquete  de  A  lacrdn    9 1 

que  los  sintomas  generales,  y  el  enfermo,  al  recobrar  la  salud,  no 
conserva  ninguna  perturbacion  del  lado  de  sus  ojos. 

Pero  no  sucede  siempre  asf:  a  las  contracturas  de  los  miisculos 
extrinsecos  o  intrinsecos  del  periodo  de  excitacion,  siguen  paresias 
mds  o  menos  acentuadas  y  hasta  verdaderas  pardlisis,  y  como  estas 
suelen  persistir  no  solamente  dias,  sino  hasta  semanas,  puede  pasar 
inadvertida  para  el  oculista  la  verdadera  causa  que  las  produje, 
cuando  el  enfermo  no  da  ensenanzas  sobre  el  particular. 

Personas  completamente  sanas  de  sus  ojos  y  que  no  se  quejaban  de 
ninguna  perturbacion  visual  antes  de  sufrir  el  piquete  del  alacran, 
vienen  al  consultorio  a  contarnos  que,  desde  que  lo  sufrieron,  no 
pueden  ver  como  antes,  que  los  objetos  lejanos  les  parecen  borrosos  o 
que  les  es  imposible  leer.  El  examen  descubre,  unas  veces,  pardlisis 
de  los  miisculos  extrinsecos,  en  ocasiones  tan  leves,  que  no  provocan 
desviacion  de  los  ejes  oculares  y  solo  pueden  ser  descubiertas  por  el 
examen  con  los  vidrios  coloridos,  que  hacen  aparecer.  la  diplopia; 
otras  veces,  lo  linico  que  hallamos  es  la  paralisis  de  la  acomodacion 
que  nos  obliga  a  prescribir  al  enfermo — mientras  por  otros  medios  la 
hacemos  ceder — el  porte  de  cristales  de  +  1-50  D.  a  +  2  D.,  para 
los  trabajos  de  cerca. 

Debo  advertir  que  he  tenido  oportunidad  de  observar  el  cuadro 
dramdtico  del  envenenamiento,  en  personas  perfectamente  sanas  de 
sus  ojos,  y  en  las  que,  despues,  he  encontrado  las  paralisis  y  las 
paresias  de  los  musculos  oculares  que  acabo  de  senalar,  asi  es  que  no 
abrigo  duda  sobre  esta  accion  del  veneno  del  alacran. 

Pero  si  estas  complicaciones  no  carecen  de  importdncia,  mucha 
mayor  la  tienen  las  que  voy  a  describir  en  las  observaciones  siguientes, 
tanto  porque  en  estos  casos  la  ceguera  absoluta  persistio  por  algunos 
dias,  como  porque  parecen  demostrar  que  el  veneno  del  alacran  obra 
directamente  sobre  los  cordones  nerviosos,  pues,  en  uno  y  otro  caso, 
el  oftalmoscopia  permitio  ver  alteraciones  en  el  nervio  optico. 

Obs.  I. — Edema  ligero  del  nervio  optico,  con  amaurosis  completa, 
consecutivo  a  piquete  de  alacran. — Sra  A.  N.,  de  50  afios  de  edad, 
sin  antecedentes  morbosos.  Sufre  al  piquete  de  alacrdn  en  una  mano, 
estando  en  perfecta  salud;  en  seguida  se  desarrollo  todo  el  cuadro 
del  envenenamiento  que  he  descrito — hormigueos,  sialorrea,  sudor 
abundante,  convulsiones,  espasmos,  etc. — revistiendo  media  inten- 
sidad.  Desde  el  principio  note  la  enferma  que  se  nublaba  su  vista, 
pero  esperaba  que,  al  pasar  los  efectos  de  la  ponzona,  recobrarfa  su 
buena  vista  habitual :  no  f ue  asf,  sino  que  la  ceguera  se  acentu6  hasta 
llegar  a  ser  completa. 


92  JOSE  DE  JESUS  GONZALEZ 

Al  dia  siguiente  del  piquete,  el  examen  ocular  me  revelo  la  completa 
normalidad  en  el  exterior  de  ambos  ojos,  asf  como  la  integridad  de 
todos  los  movimientos  del  globo.  Ambas  pupilas  estaban  dilatadas 
y  no  respondian  al  estfmulo  luminoso,  ni  a  la  convergencia.  Agudeza 
visual,  nula.  Por  el  examen  oftalmoscopico  encuentro  los  medios 
transparentes;  pero  las  dos  papilas  estaban  ligeramente  edematosas: 
contornos  borrosos,  mayor  didmetro  que  el  habitual,  venas  mds 
gruesas  que  normalmente.  Ningiin  otro  sintoma  oftalmoscopico. 
Tension  normal  en  los  dos  ojos.  Ningiin  dolor,  ni  espontdneo  ni  a  la 
presi6n. 

Atribui  el  edema  de  los  nervios  opticos  a  la  unica  causa  que  me 
senalaban  los  antecedentes :  la  ponzona  del  alacrdn,  y  como  la  pobre 
enferma  casi  no  habia  tenido  asistencia  medica  durante  lo  agudo  de  su 
envenenamiento,  recurri  a  una  inyeccion  de  cloruro  de  philocarpina, 
para  eliminar  las  ultimas  cantidades  de  ponzona;  los  resultados 
fueron  favorables,  pues  la  enferma  empezo  a  ver.  En  los  dias  sigui- 
entes  prescribi  1  gr.  diario  de  yoduro  de  sodio,  cuya  accion  sobre  el 
exsudado  papilar  me  parecio  eficaz,  pues  en  una  semana  el  aspecto 
del  fondo  del  ojo  se  volvio  normal  y  la  enferma  recobro  completa- 
mente  la  vista. 

Obs.  II. — Ceguera  completa,  con  pocos  sintomas  oftalmoscopicos, 
consecutiva  a  piquete  de  alacrdn. — Una  jovencita  de  17  afios,  de  buena 
constitution  y  en  pleno  estado  de  salud,  sufre  el  6  de  diciembre  de 
1920,  un  piquete  de  alacrdn  en  una  mano,  seguido  de  todos  los  sin- 
tomas de  envenenamiento  y  de  ceguera  completa  que  persistio  24 
horas  despues  que  habia  desaparecido  todo  peligro.  No  la  observe 
entonces. 

El  28  de  diciembre  del  mismo  ano,  es  decir,  a  penas  tres  semanas 
mas  tarde,  sufre  neuvo  piquete  de  alacrdn  en  el  antebrazo  izquierdo. 
En  esta  vez  los  fenomenos  de  envenenamiento  fueron  mucho  mas 
intensos:  trismus,  espasmo  faringeo,  convulsiones  tetaniformes,  fe- 
nomenos asfixicos  y  perdida  de  conocimiento.  La  enferma  estuvo 
luchando  entre  la  vida  y  la  muerte  durante  24  horas.  Al  volver  a 
la  plena  conciencia  de  si  misma,  noto  que  no  vela  absolutamento. 

No  recurrio  a  mis  cuidados  sino  hasta  despues  de  ocho  dias  y 
cuando  ella  y  sus  padres  habian  ya  perdido  toda  esperanza  de  que  se 
recobrara  la  vista  espontdnearnente.  Entonces  encontre  lo  siguiente: 

Ningiin  sfntoma  nervioso  general. 

Movimientos  normales  de  los  globos  oculares  y  de  los  pdrpados. 

Exterior  de  ambos  ojos,  normal.     Tension,  normal. 


Sintomas  Ocular  es  del  Envenenamiento  por  el  Piquete  de  A  lacrdn     93 

Pupilas  midriaticas — cinco  milimetros  de  diametro — y  sin  reac- 
cionar  a  la  luz. 

Agudeza  visual,  nula:  la  enferma  no  distiguia  la  luz  de  la  oscuridad. 

Al  oftalmoscopio  encontre"  los  medios  transparentes;  en  el  fondo 
del  ojo  unicamente  se  veian  ambas  papilas  muy  rojas,  pero  el  calibre 
de  los  vasos  era  normal  y  los  contornos  papilares  bien  limitados. 

La  absoluta  ceguera  de  la  enferma,  con  tan  pocas  alteraciones 
oftalmoscopicas,  me  hizo  pensar  tanto  en  una  neuritis  retrobulbar — 
por  la  hiperemia  papilar  tan  evidente — como  en  una  accion  estupe- 
faciente,  sobre  la  retina,  de  la  ponzona  del  alacrdn. 

La  sudacion  provocada  por  una  sola  inyeccion  de  pilocarpina,  y 
una  serie  de  inyecciones  de  estricnina  como  tonico  retiniano,  fueron 
poco  a  poco  mejorando  a  la  enferma,  que  recobro  su  vista  en  el  breve 
espacio  de  doce  dias. 

Este  caso  es  interesante  por  haberse  presentado  dos  veces  la  ceguera 
en  la  misma  persona,  y  de  mayor  duracion  en  el  segundo  piquete.  como 
si  se  hubiera  producido  anafilaxia. 

DISCUSSION 

DR.  FRANCISCO  M.  FERNANDEZ  (Havana,  Cuba) :  As  Colonel  Elliot  has 
well  said  in  his  book  on  "Tropical  Ophthalmology,"  which  I  have  just  had  the 
pleasure  of  translating  into  Spanish,  the  ocular  lesions  caused  by  the  arthro- 
pods in  the  different  tropical  countries  chiefly  depend  upon  what  part  of  the 
tropics  they  are  observed,  but  are  all  much  the  same  all  over. 

We  have  had  no  occasion  of  observing  in  Cuba  the  cases  described  by  Dr. 
Gonzalez,  perhaps  because  the  scorpions  we  have  there  are  not  of  the  dan- 
gerous Durango  variety  identical  to  the  Centrums  exilicauda;  and  their  bites 
do  not  give  rise  to  serious  toxic  symptoms,  either  general  or  ocular,  but  only 
to  local  manifestations. 

The  insectivorous  life  in  Cuba  is  not  abundant,  and  outside  of  the  frequent 
cases  of  small  flying  insects  that  produce  conjunctivitis,  we  can  only  remember 
now  some  cases  of  conjunctivitis  of  more  serious  nature  produced  by  the 
toads  that  have  been  described  by  our  teacher,  Santes  Fernandez,  and  that 
have  presented  a  violent  characteristic.  These  cases,  however,  have  been  pro- 
duced by  the  local  access  of  the  secretion  in  the  conjunctival  sac  and  have  not 
given  rise  to  any  general  toxic  manifestations. 

DR.  AURELIO  BERAUN  (Peru) :  Ocular  lesions  caused  by  the  bite  of  the 
scorpion  are  rare  in  Peru,  The  paper  is  important  and  the  symptomatology 
is  well  described.  I  have  had,  however,  no  experience. 

COLONEL  R.  H.  ELLIOT  (London,  England) :  I  would  like  to  take  this  in- 
ternational opportunity  to  direct  attention  to  the  fact  that  work  in  the 
tropical  branches  of  ophthalmology  has  been  very  scanty.  Very  little  indeed 
has  been  done,  for  instance,  on  the  stings  of  scorpions  and  insects  of  various 
kinds. 


94  JOSE  DE  JESUS  GONZALEZ 

May  I  start  with  the  analogy  of  snake  poisons?  Some  years  ago  I  worked 
out  the  physiology  of  cobra  venom.  It  was  then  generally  assumed  that  if  one 
had  worked  out  one  snake's  venom,  one  had  worked  out  the  venom  of  all 
snakes;  but  I  soon  found  that  there  was  a  difference  between  cobra  venom 
and  that  of  the  other  colubrine  snakes  (e.  g.,  the  karcut  and  the  sea  snakes), 
and  a  much  wider  difference  still  between  the  venom  of  colubrine  snakes  and 
that  of  vipers.  I  believe  the  same  thing  is  true  of  the  stings  of  scorpions  in 
different  parts  of  the  world,  and  that  they  are  each  specific  in  their  action. 
Indeed,  the  natives  of  India  will  tell  you  that  the  little  white  scorpion's  bite 
is  worse  than  that  of  the  large  black  one  in  the  same  district.  We  have  heard 
today  that  an  ophthalmologist  working  in  one  area  has  found  definite  symp- 
toms after  scorpion  stings,  while  the  rest  of  us  have  seen  a  large  number  of 
scorpion  stings  without  any  of  these  symptoms.  I  would  suggest  that  it  is  a 
matter  of  the  specificity  of  the  poison  in  question. 

.After  experimenting  with  snake  poisons  I  worked  a  little  with  scorpion  poi- 
son, and  I  was  led  to  believe  that  the  action  of  scorpion  poison  is  closely 
allied  to  viper  poison.  Even  here  there  are  specific  differences — the  intense 
pain  of  scorpion  sting  is  an  illustration  of  this.  I  believe  that  scorpion 
poison  runs  along  much  the  same  line  as  the  viperine  venom,  and  I  want 
to  make  two  suggestions  to  Dr.  Goflzales:  (1)  One  of  the  characteristics  of 
viperine  poison  is  the  clotting  that  occurs  in  the  small  vessels  all  over  the 
body  with  hemorrhages  following.  It  would  be  interesting  to  know  whether 
in  any  of  these  cases  of  severe  scorpion  poisoning  you  get  such  hemorrhages. 
(2)  Running  right  through  all  the  snake  poisons  I  have  worked  with  is  the 
tendency  to  vasomotor  constriction.  To  test  for  this  I  perfused  the  vessels  of 
the  frog  with  a  weak  solution  of  various  venoms,  and  regularly  found  a  marked 
tendency  to  vasomotor  constriction.  May  it  not  be  that  the  blindness  spoken 
of  by  Dr.  Gonzalez  as  a  result  of  scorpion  poison  is  due  to  a  special  con- 
striction of  the  retinal  and  choroidal  circulation,  an  exaggeration  of  the  gen- 
eral vasoconstriction  which,  as  I  have  shown,  runs  through  all  snake  poison- 
ing? I  would  like  to  persuade  men  who  are  working  in  the  tropics  to  take  up 
these  questions  of  the  eye  symptoms  of  snake,  scorpion  and  allied  poisons.  I 
believe  they  will  get  a  harvest  of  material  from  it. 

DR.  LLOYD  MILLS  (Los  Angeles,  Cal.) :  I  had  some  experience  in  this  sub- 
ject in  1910.  I  was  invited  by  the  Southern  Pacific  Railroad  Company  of 
Mexico  to  investigate  the  reason  why  scorpions  were  holding  up  the  construc- 
tion of  their  road.  Their  road  passes  through  some  old,  ruined  Aztec  villages, 
and  when  the  adobe  walls  were  torn  down  scores  of  these  scorpions  would 
run  out,  and  the  men  were  stung  on  their  feet  and  hands.  Twenty  or  thirty 
workmen  were  seriously  ill.  Five  small  children  and  two  old  people  died.  At 
that  time  no  particular  attention  was  paid  to  eye  conditions,  as  our  object  was 
the  development  of  an  anti-venom.  We  took  six  puppies  of  the  same  weight 
and  injected  them  with  a  mixed  venom  from  the  same  type  of  scorpion,  using 
an  increasing  dose,  from  1  to  6.  All  of  these  animals  were  examined  after  four 
hours  and  at  two-hour  intervals,  and  we  found  the  main  objective  condition 
to  be  an  increasing  meningeal  congestion  with  an  increased  quantity  of  fluid 
in  the  meninges,  to  the  point  that  I  was  led  to  believe  that  many  of  the  general 
symptoms  were  due  to  a  serous  meningitis,  though  the  neurotoxic  symptoms 


Traitement  du  Trachome  95 

were  the  predominating  ones.  I  would  not  be  surprised  if  routine  examination 
of  the  fundus  in  the  graver  cases  would  show  various  phases  of  a  neuroretinal 
congestion  with  a  distinct  swelling  of  the  disc  in  the  more  decided  cases,  the 
main  source  of  these  changes  probably  being  found  in  the  serous  meningitis. 


TRAITEMENT  DU  TRACHOME  PAR  LES  INJECTIONS 

SOUS   CONJONCTIVALES  DE  CYANURE  DE 

MERCURE 

DR.  S.  GEMBLATH 
Paris,  France 

A  defaut  de  substances  reellement  specifiques  dans  le  traitement  du 
trachome  nous  possedons  une  foule  de  moyens  medicaux  et  chirurgi- 
caux  pour  arreter  Fextension  du  processus  morbide,  sinon  pour  le 
faire  disparaitre  completement.  Une  des  conditions  essentielles  pour 
que  les  methodes,  d'ordre  purement  medical,  soient  efficaces  c'est  que 
leurs  applications  soient  repetees  pendant  de  longs  mois  et  meme  des 
annees.  Les  procedes  chirurgicaux  sont  plus  energiques,  plus  satis- 
faisants  et  reduisent  la  duree  du  traitement.  Malheureusement  leur 
action  est  temporaire  et  ils  ne  sont  pas  sans  inconvenients.  Tout  le 
monde  connait  les  cicatrices  et  les  consequences  facheuses  des  causti- 
ques  violents  et  des  scarifications  trop  etendues.  De  plus,  employes 
seuls,  ces  precedes  sont  insuffisants  a  realiser  une  cure  radicale.  II 
fallait  un  precede  energique,  rapidement  efficace  et  laissant  le  moins 
de  sequelles  possibles.  Le  probleme  nous  semble  resolu  par  Pemploi 
des  injections  sous  conjoncti vales  de  cyanure  Hg,  qui  offre  sur  le 
jequirity  un  avantage  pratique,  c'est  d'etre  d'un  dosage  sur  et  d'un 
maniement  facile. 

Bien  que  le  virus  ne  soit  pas  encore  connu,  il  est  incontestable  que 
cette  affection  est  d'ordre  infectieux;  on  a  done  cherche,  depuis  bien 
des  annees,  a  exercer  une  action  bactericide.  Tous  les  antiseptiques 
y  ont  passe  meme  le  cyanure.  Mais  si  les  lesions  ont  persiste,  ou 
paru  peu  influencees,  ce  n'est  point  a  cause  d'une  resistance  par- 
ticuliere  du  virus,  mais  bien  en  raison  du  siege  profond  des  lesions  sous 
la  mu.queuse  siege  qui  parait  les  soustraire  a  1'action  des  antiseptiques 
employes  superficiellement.  Deja  les  anciens  s'etant  rendu  compte 
de  ce  fait  avaient  conseille"  le  massage,  le  raclage,  le  brossage  ou  les 
scarifications.  De  nos  jours  on  preconise  1'electrolyse  ou  la  galvano- 
caustie  selon  la  methode  d'Abadie.  Ces  methodes  peuvent  etre  con- 


96  S.  GEMBLATH 

sider£es  comme  satisfaisantes,  mais  nettement  inferieures  aux  injec- 
tions de  cyanure. 

Ce  proce'de'  n'est  pas  absolument  nouveau.  En  Novembre  1920 
deux  Docteurs  Roumains,  MM.  Lobel  et  Stiacovici  en  parlaient  dans 
une  communication  publiee  dans  les  Archives  d'Ophtalmologie  (de 
Paris) .  Us  le  conseillaient  dans  les  cas  d'ulceres  par  suite  de  trachome. 
Leur  technique  differe  un  peu  de  la  notre.  De  plus  ce  precede  nous 
etait  parfaitement  inconnu  lors  de  nos  premiers  essais. 

Travaillant  a  1'Hotel-Dieu  de  Paris,  dans  le  service  de  M.  le  pro- 
fesseur  de  Lapersonne,  il  nous  a  e'te  donne  de  constater  chez  presque 
tous  les  malades  a  hypopion  a  qui  nous  faisions  des  injections  sous 
conjonctivales  de  CyHg  un  epaississement  de  la  conjonctive  avec 
formation  de  tissu  fibreux.  Un  genre  de  cicatrice  se  presentant  sous 
la  forme  d'une  plaque  plus  ou  moins  grande  a  1'endroit  ou  avait  eu 
lieu  1'injection;  ce  tissu  etait  plus  ou  moins  transparent,  blanc, 
jaunatre,  adherent  au  tissu  sous  adjacent,  parfois  assez  terne,  conser- 
vant  toujours  cependant  sa  vitalite"  et  sa  sensibilite.  Nous  nous 
sommes  demandes  quel  pouvait  etre  1'effet  d'un  pareil  traitement 
dans  les  cas  de  pannus  trachomateux.  II  nous  a  e'te  permis  de 
1'essayer  sur  un  trachomateux  qui  se  trouvait  alors  dans  le  service, 
(observation  1).  Notre  maftre,  qui  suivait  les  malades,  nous  encouragea 
a  continuer  et  nous  guida  darts  notre  etude  par  ses  conseils  bien- 
veillants. 

Aujourd'hui,  bien  que  nos  essais  soient  a  leur  debut,  nous  croyons 
utile  de  faire  part  a  Nos  Confreres  Ophtalmologistes  de  ce  precede 
centre  ce  veritable  fleau  qu'est  le  trachome.  Nous  esperons  qu'ils 
contribueront  au  perfectionnement  de  ce  nouveau  precede  the'ra- 
peutique  qui  nous  parait  devoir  rendre  service  dans  1'avenir. 

TECHNIQUE 

La  technique  est  tres  simple:  1.  Instillation  de  4  gouttes  de 
cocaine  a  4%  a  1  minute  d'intervalle.  L'anesthesie  faite,  le  malade 
est  couche:  cette  position  n'est  pas  absolument  necessaire,  elle  doit 
etre  choisie  dans  le  cas  ou  le  malade  est  indocile  ou  pusillanime. 

2.  Si  la  fente  palpebrale  est  retr^cie,  par  suite  de  processus  in- 
flammatoire,  ou  lorsqu'il  existe  du  blepharospasme,  on  place  un 
blepharostat.  Dans  le  cas  contraire  et  lorsque  le  malade  est  facile, 
il  suffit  d'e"carter  les  paupieres  avec  le  pouce  et  1'index  de  la  main 
gauche.  On  fixe  la  conjonctive  avec  une  pince  en  prenant  toute 
precaution  utile  pour  ne  pas  la  dechirer.  On  souleve  alors  l^gere- 


Traitement  du  Trachome  97 

ment  la  conjonctive  qui  fait  un  pli  on  enfonce  rapidement  mais  pru- 
demment  1'aiguille  d'une  seringue  de  1  cm3.  On  injecte  lentement  la 
solution  suivante: 

1.  Solution. 

Cyanure  d'hydrargyre  un  milligr. 
Eau  distillee — un  centimetre  cube. 

2.  Solution. 

Novocaine — deux  centigr. 
Adrenaline  au  millieme — deux  gouttes. 
Eau  distillee — un  centimetre  cube. 

Prendre  dans  la  seringue  de  1  c3,  une  partie  de  la  solution  N°  1  et  une 
partie  de  la  solution  N°  2. 

Une  fois  au  courant  de  la  technique  des  injections  sous  conjoncti- 
vales  on  fera  mieux  d'eviter  1'emploi  de  la  pince  a  fixation.  De  plus 
pour  diminuer  les  risques  d'ecchymoses,  nous  conseillons  1'usage 
d'aiguilles  tres  fines.  Ceci  diminuera  les  chances  d'issue  du  liquide 
injecte,  car  il  a  tendance  &  ressortir  dans  les  cas  ou  il  est,  pour  ainsi  dire, 
sous  pression  par  suite  de  Phyperemie  conjonctivale  et  de  I'oedeme 
inflammatoire,  choses  frequentes  dans  le  trachome  aigu. 

Si  on  procede  lentement,  le  liquide  se  diffuse,  soulevant  la  con- 
jonctive en  une  boule  qui  contourne  la  cornee,  sans  avoir  a  repiquer 
et  sans  faire  avancer  1'aiguille.  II  nous  semble  qu'en  agissant  ainsi 
on  diminue  la  frequence  des  ecchymoses  en  diminuant  le  nombre  des 
vaisseaux  lese"s  ou  coupes  au  passage.  Un  pansement  suffisamment 
•compressif  est  applique  pendant  12  a  24  heures  selon  la  tolerance  du 
malade.  S'il  arrive  que  le  malade  se  plaint  de  quelques  douleurs  on 
desserre  un  peu  le  pansement.  Quelquefois  la  suppression  complete 
et  definitive  de  la  bande  est  la  seule  chose  qui  assure  un  soulagement. 
Souvent  il  faut  avoir  recours  a  1'aspirine. 

En  presence  de  douleurs  parfois  intenses  chez  les  jeunes  sujets 
nous  avons  pu  les  prevenir  completement,  en  administrant  au  malade 
O  gr  50  d'aspirine  une  demi-heure  avant,  O  gr  50  au  moment  meme  de 
la  piqure  et  0  gr  50  enfin  deux  heures  apres.  Le  soir  meme  ou  le  lende- 
main  on  fait  appliquer  des  compresses  chaudes  3  fois  par  jour  et  des 
compresses  froides  les  jours  suivants.  Cinq  jours  de  repos  et  au 
sixieme  une  nouvelle  injection  au  meme  endroit  ou  du  cote  diametrale- 
ment  oppose  s'il  y  a  lieu. 

Comme  inconvenients,  a  part  la  douleur,  nous  n'en  connaissons  pas 

qui  contredisent  Femploi  de  cette  methode.     Et  encore  avec  1'usage 

d'aspirine   arrive-t-on   a   prevenir   toute   douleur.    D'ailleurs   elles 

diminuent  progressivement  mais  rapidement  apres  chaque  piqure. 

7 


98  S.  GEMBLATH 

Est-ce  la  un  phenomene  d'accoutumance  de  la  conjonctive?  Nous 
somraes  plutot  enclins  a  voir  la  cause  dans  1'amelioration  de  l'e"tat 
ge'ne'ral  du  sujet  et  de  1'etat  local  de  la  conjonctive  apres  les  premieres 
injections.  Ce  qui  confirme  cette  idee  c'est  le  peu  de  reaction  chez 
les  personnes  dont  les  yeux  sont  peu  enflammeX  comme  dans  les  cas 
regents  de  plaies  pene'trantes  du  globe. 

Un  autre  moyen  nous  a  paru  tres  efficace  centre  les  douleurs;  c'est 
les  compresses  chaudes  qui,  si  elles  sont  appliquees  quelques  minutes 
apres  1'injection,  re*duisent  a  rien  la  reaction  et  les  douleurs. 

En  suivant  cette  technique,  on  n'a  pas  d'hematome  et  d'ecchymose 
sous  con joncti vale,  peu  esthetiques,  et  assez  frequents  dans  les  cas  de 
pannus.  Si  on  tient  compte  de  la  solution  de  cyanure:  1:2000  on 
eVite  les  eschares  et  les  cicatrices  qui  en  resultent. 

RESTJLTATS 

Au  moment  meme  de  1'injection,  si  la  solution  est  bien  faite  et  la 
conjonctive  bien  anesthesiee,  le  malade  ne  sent  absolument  rien. 
Une  demiheure  apres  apparait  une  gene,  se  traduisant  par  une 
lourdeur  generate  de  la  tete  des  battements  dans  les  tempes,  et 
une  sensation  de  douleur  dans  la  region  oculaire  dont  Pintensite  va 
en  augmentant  jusqu'a  une  heure  et  demie  apres  1'injection,  pour 
diminuer  petit  a  petit  et  disparaitre  completement  3  heures  apres. 
Si  on  a  eu  soin  de  donner  au  malade  O  gr  50  d'aspirine  au  moment  de 
1'injection,  les  phenomenes  subjectifs  se  reduisent  a  ce  qu'un  de  nos 
malades  a  essayer  de  nous  decrire  "Je  ne  souffre  pas  mais  mon  oeil 
est  tirailleV'  Si  on  enleve  alors  le  pansement  et  qu'on  examine  le 
malade,  on  constate  un  oedeme  hyperemique  des  paupieres  celles-ci 
deviennent  souvent  tres  volumineuses  et  la  tumefaction  descend 
parfois  jusqu'a  la  joue.  Tous  les  tissus  paraissent  imbibes  jusque 
dans  leur  profondeur.  Le  chemosis  est  considerable  enveloppant 
pour  ainsi  dire  une  grande  partie  de  la  corne"e  qui,  a  cette  periode,  ne 
parait  pas  etre  changee.  Le  surlendemain  tout  rentre  dans  1'ordre. 
Le  3e  jour  un  changement  apparait  sur  la  cornee  qui  devient  plus 
nette  le  4e  jour.  La  corner  s'eclaircit,  les  vaisseaux  qui  la  sillonnent 
diminuent  de  calibre  et  deviennent  filiformes.  Vers  le  4e  ou  5e  jour 
apparait  sur  la  conjonctive  la  formation  du  tissu  fibreux  de"ja  decrite. 
Vers  le  7e  ou  8e  jour  les  petits  vaisseaux  qu'on  n'apercevait  qu'a 
Pe'clairage  oblique  ne  se  voient  plus.  Vers  cette  e"poque,  s'il  existe 
(ce  qui  est  fort  probable)  de  1'opacite  corne"enne,  on  assiste  a  1'eclair- 
cissement  constamment  progressif  de  la  cornee.  Vers  le  lle  ou  12e 


Traitement  du  Trachome  99 

jour,  c'est  a  dire  apres  la  2e  injection,  on  constate  un  fait  des  plus 
curieux  et  des  plus  interessants,  que  nous  avons  constamment  vu 
chez  nos  malades:  les  gros  vaisseaux  du  pannus,  qui  sont  devenus 
filiformes  mais  qui  restent  encore  visibles  a  cette  periode,  pre"sentent 
sur  le  limbe  comme  un  arret  brusque,  une  zone  exangiie  de  1  a  1^ 
mm.  A  ce  niveau  leur  trajet  donne  tout  a  fait  1'aspect  d'une  embolie, 
alors  que  les  vaisseaux  correspondants  sur  la  conjonctive  se  con- 
tinuent  avec  un  volume  environ  2  fois  plus  grand.  Ce  n'est  que  du 
15e  au  18e  jour,  c'est  a  dire  apres  la  3e  injection,  que  les  derniers 
restes  des  vaisseaux  sanguins  deviennent  invisibles.  De  1'opacite" 
corneenne  totale,  il  ne  reste  qu'un  leger  nephelion  central  qui  diminue 
d'etendue  petit  a  petit  pour  disparaitre  completement. 

Nous  avons  ete  tres  frappes  durant  le  cours  du  traitement  de  notre 
premier  malade  Obs.  I  de  voir  1'etat  des  conjonctives  palpebrales,  sur- 
tout  au  niveau  des  culs  de  sac,  s'ameliorer  d'une  fagon  tres  rapide  et 
tres  marquee.  (Trois  a  quatre  jours  apres  1'injection  on  constate  1'af- 
faissement  des  follicules  et  des  granulations  conjonctivales.  Mais  la 
conjonctive  parfaitement  lisse  reste  hyperemiee.  A  la  place  des  grosses 
granulations  on  voit  de  petites  tach.es  plus  ou  moins  transparentes 
jaune  gelatineux,  grosses  comme  des  grains  de  semoule.  Une  semaine 
ou  deux  de  nitrate  d'argent  rende  a  la  conjonctive  son  aspect  et 
sa  coloration  normale.)  Nous  avons  d'abord  pense  que  le  cyanure 
avait  agi  sur  les  paupieres  de  la  meme  fagon  qu'il  avait  agi  sur  la 
cornee,  par  reaction,  ou  par  formation  de  tissu  cicatriciel  ou  par 
action  bactericide — Mais  devant  1'amelioration  tres  nette  et  tres 
rapide  nous  nous  demandons  si  le  cyanure  n'aurait  pas  une  action 
directe  nous  n'osons  pas  dire  specifique  sur  le  virus  trachomateux. 
Le  nombre  limite  de  nos  experiences  ne  nous  permet  pas  de  nous 
prononcer.  II  faudrait  aussi  pour  cela  des  cas  vierges  traites  ex- 
clusivement  au  cyanure.  La  date  du  Congres  ne  nous  a  pas  permis 
de  le  faire.  Mais  dores  et  deja  nous  pouvons  justifier  de  I'efficacite 
de  la  methode  par  ces  resultats. 

La  methode  est  applicable  a  tous  les  cas  et  tous  en  be"neficient  = 
Restitutio  ad  integrum  dans  les  cas  legers  de  pannus  (5  ou  8  jours 
apres  1'injection.) — Meme  resultat  sur  la  conjonctive  palpebrale  dans 
tous  les  cas  de  la  le  et  2e  periodes:  toutes  les  granulations  dis- 
paraissent  en  moins  de  3  semaines,  et  la  conjonctive  re"cupere  son 
aspect  normal  avec  une  ou  deux  semaines  de  nitrate  d'argent  ou  de 
sulfate  de  cuivre — Dans  les  cas  plus  marques  de  pannus,  avec  trouble 
considerable  de  la  cornee,  la  guerison  est  moins  rapide.  On  peut 


100  S.  GEMBLATH 

esperer  la  disparition  totale  et  complete  des  ne'phe'lions  pas  trop 
anciens  et  du  trouble  diffus  de  la  cornee.  Le  cyanure  est  sans  action 
appreciable  sur  les  leucomes  e"tendues  ainsi  que  sur  1'hypertrophie  du 
tarse  et  de  la  conjonctive,  avec  formation  de  tissu  scleYeux. 

Dans  les  cas  graves  et  anciens,  combines  au  nitrate  d'argent  ou  au 
sulfate  de  cuivre,  le  cyanure  diminue  d'une  facon  considerable  la 
dur6e  du  traitement.  Dans  tous  les  cas,  le  r6sultat  fonctionnel  est, 
comme  on  le  voit,  des  plus  encourageant. 

Nous  posse1  dons  vingt  observations  suivies  plusieurs  mois.  Les 
resultats  obtenus  sont  a  peu  pres  les  memes  dans  tous  les  cas.  Nous 
donnons  seulement  le  resume  de  quatre  observations  les  plus  car- 
act6ristiques. 

OBSERVATION  I. — Trachome  tres  ancien  non  soigne  72  ans. 

ODG. — S6cr6tion  larmoiement.  Blepharospasme,  faux  ptosis, 
e'paississement  de  la  conjonctive  et  du  tarse.  Pannus  crassus,  cornees 
ternes  et  tres  vascularisees  empechant  de  voir  1'iris. 

OD. — Mou  et  douloureux  peut  etre  iridocy elite.  La  vision  de  cet 
oeil  est  r6duite  a  la  perception  lumineuse.  VOG  =  compte  les 
doigts  a  ^2  metre.  Du  19  De"c.  1920  au  16  Janvier  1921  traite"  sans 
resultat  appreciable  au  sulfate  de  cuivre. 

2  Janvier.  Injection  de  cyanure  a  1'  O.D.  Reaction  assez  mar- 
quee hematome  sous  conjonctival.  Le  10  1'hematome  est  resorbe. 
Cornee  moins  terne  et  moins  vascularise'e.  Conjonctive  moins  rouge 
considerablement  amelioree.  L'oeil  droit  propre  et  bien  ouvert. 
Sulfate  de  cuivre. 

Le  23  Janvier.  Injection  de  cyanure  a  1'  O.G.  Dix  jours  apres  le 
malade  se  conduit  seul. 

VOG.  =  TV  Corne'e  presque  completement  transparente,  permet 
de  voir  une  cataracte  intumescente. 

OD. — Infiltration  16gere  et  diffuse  de  toute  la  cornee  cataracte  en 
Evolution. 

Sort  de  1'hopital  appele  chez  lui  d'urgence.  Collyre  au  sulfate  de 
cuivre.  Admis  a  nouveau  le  11  Mars  pour  etre  opere  de  cataracte. 
12  Mars:  Iridectomie  preparatoire. 

Un  mois  apres  extraction.     Suites  normales. 

OBSERVATION  II. — L'interet  de  cette  observation  est  dans  la 
guerison  tres  rapide  du  pannus  et  des  granulations  par  le  cyanure; 
elle  demontre  bien  la  superiority  de  ce  procede  sur  les  moyens  ordi- 
naires. 

M Jeune  Grec,  docteur  en  me'decine.     Soigne"  depuis  2  ans 


Traitement  du  Trachome  101 

chez  lui  et  a  Paris  pour  trachome  par  du  nitrate  d' argent  et  du  sulfate 
de  cuivre. 

OD:  Cornee  normale.  Quelques  granulations  ty piques  dans  le 
cul  de  sac  conjonctivale  sup.  et  sur  le  bord  du  tarse. 

OG:  Photophobie  et  larmoiement  intenses.  La  conjonctive 
palpe"brale  tres  hype'remiee  est  entierement  couverte  de  granulations. 
Pannus  typique  du  tiers  supe"rieur.  On  devine,  a  travers  le  trouble 
de  la  cornee,  la  pupille  en  myosis.  VOG  =  Voit  passer  la  main. 

10  Mars  1921.  Injection  de  cyanure  a  1'  O.G.  Reaction  tres  in- 
tense. Le  15,  Vascularisation  occupant  les  %  sup.  de  la  cornee. 

Le  18,  les  vaisseaux  diminuent  pour  disparaitre  completement  le 
22.  Nitrate  d'argent  en  application  quotidienne. 

10  Juin.  Cornee  transparente,  conjonctive  parfaitement  lisse  sans 
granulation  ni  cicatrice,  de  couleur  et  d'aspect  normal.  VOG  =  1. 

OD:  Soigne  seulement  par  le  nitrate  d'argent  presente  une  conjonc- 
tive legerement  injectee  mais  beaucoup  moins  qu'avant  avec  quelques 
granulations  vers  Tangle  externe.  VOD  =  1. 

OBSERVATION  III  AND  IV. — Ces  cas  ne  sont  pas  moins  interessants. 
II  s'agit  de  deux  jeunes  Syriens,  refuses  a  2  reprises  par  les  Medecins 
inspecteurs  du  port  de  New  York  entre  Aout  et  Decembre  1920. 
Renvoyes  a  Paris  pour  la  deuxieme  fois  ils  consultent  a  1'Hotel-Dieu 
et  subissent  deux  injections  de  cyanure  dans  les  deux  yeux  suivies 
de  deux  semaines  de  sulfate  de  cuivre.  Au  mois  de  Mars  1921  c'est 
a  dire  deux  mois  apres  ils  entrent  a  New  York  sans  difficulte. 

DISCUSSION 

DR.  J.  M.  PENICHET  (Havana,  Cuba) :  I  have  no  doubt  that  Dr.  Gemblath 
has  been  successful  in  the  treatment  of  trachoma  and  its  complications  with 
the  subconjunctival  injections  of  cyanid  of  mercury.  We  all  have  had  cases 
of  trachoma  radically  cured  by  one  of  the  many  methods  employed  to  treat 
this  affection  and,  vice  versa,  we  all  have  employed  almost  every  known 
method  on  some  difficult  case  without  any  or  with  very  little  success. 

The  point  to  consider  is  whether  we  are  dealing  with  a  simple  case  or  with 
a  complicated  one.  As  a  rule,  trachomatous  ulcers  of  the  cornea  and  pannus 
do  not  yield  to  all  forms  of  subconjunctival  injections.  That  is  why  the  results 
obtained  by  Dr.  Gemblath  should  be  taken  into  consideration. 

To  prove  my  statement  I  will  say  that  four  years  ago  I  tried  the  subcon- 
junctival auto  vaccine  treatment  introduced  by  Dr.  Demaria  of  the  Argentine 
Republic,  and  with  only  a  slight  modification  in  the  technic  I  used  it  in  twenty 
cases  of  simple  trachoma  and  five  cases  of  ulcers  and  pannus.  My  results  were 
not  as  satisfactory  as  those  of  Dr.  Demaria,  and  I  must  explain  that  I  fol- 
lowed every  one  of  these  cases  to  the  end  of  the  series.  My  impression  is  that 
the  organisms  of  trachoma  seem  to  lose  their  virulence  in  the  presence  of  or- 


102  S.  GEMBLATH 

ganisms  of  ulcer  and  of  pannus.    In  the  five  complicated  cases  better  results 
were  obtained. 

The  main  objections  to  the  use  of  subconjunctival  injections  of  cyanid  of 
mercury  are  the  pain,  the  chemosis,  and  the  psychologic  influence  of  a  bad 
appearance  upon  the  patient  and  the  family.  According  to  Dr.  Gemblath, 
aspirin  given  before,  during  and  after  the  injections  takes  away  all  possibility 
of  pain,  and  the  bandage  does  away  with  the  chemosis  and  swelling.  In  my 
experience  I  have  found,  nevertheless,  that  a  large  number  of  these  patients 
will  look  for  a  less  painful  and  easier  method. 

DR.  JOSEPH  KRIMSKY  (Brooklyn,  N.  Y.) :  In  Palestine,  where  I  had  charge 
of  a  number  of  schools  and  thousands  of  children  suffering  from  trachoma,  I 
began  to  use  cyanid  of  mercury  by  massage  instead  of  the  bichlorid,  using  a 
1  :  500  solution  with  vigorous  massage.  I  had  such  good  results  that  I  con- 
ceived the  idea  of  using  it  by  subconjunctival  injection,  and  I  can  testify  to 
what  Dr.  Gemblath  has  said,  that,  in  cases  where  there  is  an  unpleasant 
swelling  of  the  eyelids  and  chemosis  it  is  not  painful,  and  will  subside  in  a 
week.  Those  cases  in  which  I  used  the  subconjunctival  injection  recovered 
in  less  time  than  those  in  which  I  had  not  used  it.  Then  I  tried  it  in  more 
complicated  cases  where  there  was  a  thickened  pannus,  but  I  had  no  benefi- 
cial results  and  had  to  resort  to  operative  treatment. 

PROF.  F.  DE  LAPERSONNE  (Paris,  France) :  J'ai  constate"  a  1'Hotel-Dieu 
de  Paris,  les  re"sultats  obtenus  par  M.  Gemblath  dans  le  traitement  du 
trachome  par  les  injections  sous-con jonctivales  de  cyanure  Hg.  Us  sont 
extremement  encourageants  et  ce  traitement  merite  d'etre  generalise.  Avec 
la  technique  employee,  ce  traitement  est  peu  douloureux,  malgre  la  tume- 
faction considerable  des  paupieres. 

Je  ne  puis  pas  affirmer  que  dans  ce  cas  le  cyanure  agise  sp^cialement  comme 
antiseptique;  je  crois  plutot  que  c'est  par  la  reaction  inflammatoire  violente 
qu'il  produit  et  par.  L'apport  d'element  fibrineux  dans  les  tissus  sous  mu- 
queux.  II  agitait  un  peut  a  la  maniere  du  jequirity,  mais  plus  profonde"- 
ment. 

SURGEON  JOHN  MCMULLEN  (U.  S.  Public  Health  Service) :  I  am  interested 
in  the  paper  of  Dr.  Gemblath  in  so  far  as  it  would  seem  to  afford  us  a  remedy 
or  a  means  of  curing  trachoma  without  resort  to  operative  measures.  I  have 
not  used  this  particular  method,  although,  like  all  of  us,  have  covered  the 
ground  pretty  well  in  medical  treatment,  using  practically  all  the  remedies 
that  have  been  recommended.  I  shall  carry  out  the  treatment  in  the  Govern-' 
ment  Hospitals  for  the  treatment  of  trachoma  in  the  hope  that  we  may  relieve 
many  of  these  cases.  We  have  discarded  medical  treatment  to  a  great  ex- 
tent except  in  so  far  as  it  is  post-operative.  Our  treatment  of  trachoma 
is  now  altogether  surgical. 

DR.  S.  GEMBLATH  (closing) :  La  remarque  de  M.  Pe"nichet,  est  tres  juste. 
La  douleur  causee  par  les  injections  nous  a  fait  he"siter  un  moment,  mais  par 
1'usage  de  1'aspirine,  nous  avons  pu  la  re"duire  &  une  simple  gene  oculaire 
assez  bien  supported. 

Un  mot  pour  r^pondre  a  Dr.  Howe.   Comme  dans  tous  les  cas  traites  nous 


Hereditary  Ocular  Degenerations  103 

n'avons  eu  que  des  ameliorations,  sans  accidents,  nous  n'avons  pas  he'site'  a 
employer  le  cyanure  dans  les  cas  meme  tres  lagers  et  sans  lesions  corneennes. 
Mais  c'est  surtout  dans  les  cas  de  pannus  et  d'ulceres  corne'ens  que  ce  proce'de' 
donne  les  meilleurs  r^sultats. 

Les  injections  de  cyanure  contrairement  aux  proce'de's  chirurgicaux,  sont 
applicables  a  tous  les  cas  et  par  leur  diffusion,  leur  action  porte  sur  tous  les 
points,  atteints  difficilement  par  les  autres  moyens.  De  plus,  ils  ne  donnent 
pas  naissance,  comme  le  traitement  chirurgical,  a  des  cicatrices  et  a  leurs  con- 
sequences facheuses. 


HEREDITARY  OCULAR  DEGENERATIONS- 
"  OPHTHALMIC  ABIOTROPHIES  " 

MR.  E.  TREACHER  COLLINS 

London,  England 

Most  writers  on  hereditary  affections  of  the  eyes  have  omitted  to 
draw  any  sharp  line  of  differentiation  between  those  in  which  the 
tissue  involved  has  from  the  first  been  imperfectly  developed,  and 
those  in  which,  after  full  development,  degeneration  sets  in.  As  ex- 
amples of  hereditary  maldevelopments  may  be  mentioned  such  obvious 
structural  imperfections  as  microphthalmia,  ectopia  lentis,  and  con- 
genital cataract.  Also  conditions  known  to  us  best  as  functional  dis- 
turbances, though  doubtless  having  some  anatomic  basis,  such  as  con- 
genital color-blindness  and  night-blindness.  The  hereditary  ocular 
degenerations  of  which  the  fullest  information  has  been  collected  in- 
clude the  following  affections:  post-natal  cataract;  ocular  palsies; 
retinitis  pigmentosa;  symmetric  macular  pigmentary  degenerations; 
amaurotic  family  idiocy;  Leber's  optic  atrophy;  Doyne's  "family 
choroiditis  ";  nodular  and  lattice-like  degeneration  of  the  cornea. 

Widely  different  as  these  affections  may  at  first  appear,  they  will 
be  found  to  present  similar  characteristics,  which  allows  of  them  being 
grouped  together  in  a  classification  of  eye  diseases  founded  on  a  path- 
ologic basis.  All  these  diseases  are  hereditary,  in  the  sense  that  they 
may  be  met  with  in  several  siblings  of  the  same  generation,  and  all, 
with  the  exception  of  symmetric  macular  pigmentary  degeneration 
and  amaurotic  family  idiocy,  in  several  different  generations. 

The  lesions  in  all  these  diseases  are  bilateral,  and  in  none  of  them  in 
which  pathologic  investigations  have  been  made  do  the  findings  suggest 
the  presence  of  inflammation,  but  are  such  as  indicate  degeneration  in 
certain  definite  groups  of  cells — cells  which,  having  reached  a  full  de- 


104  E.  TREACHER  COLLINS 

gree  of  development  and  functional  efficiency,  have  then  undergone 
degeneration.  The  time  of  life  at  which  the  degeneration  commences 
varies,  as  also  does,  what  sometimes  appears  to  be,  the  incidental  ex- 
citing cause.  The  occurrence  of  the  degenerations  in  several  succes- 
sive generations  of  the  same  family  renders  it  impossible  to  attribute 
them  entirely  to  the  absorption  of  any  exogenous  toxic  substance,  or 
to  the  absence  of  any  exogenous  essential  nutrient  material,  such  as  a 
vitamin. 

So  far  as  our  knowledge  at  present  goes  there  is  no  endogenous  sub- 
stance, such  as  the  secretion  of  one  of  the  endocrine  glands,  upon  which 
the  structures  involved  in  these  diseases  are  dependent  for  their  vital- 
ity ;  nor  do  we  as  yet  know  of  any  toxic  material  developed  endogen- 
ously,  either  by  bacteria  or  as  the  outcome  of  some  faulty  metabolic 
process,  capable  of  poisoning  and  slaying  the  cells  picked  out  in  these 
diseases.  Even  if  such  a  toxin,  or  internal  secretion,  be  discovered  to 
account  for  the  hereditary  nature  of  the  affections,  it  will  still  be 
necessary  to  assume  some  innate  weakness  in  the  cells  attacked;  or, 
in  the  case  of  some  internal  nutrient  secretion,  some  innate  tendency 
to  a  failure  in  its  supply. 

Sir  William  Gowers  accounted  for  the  hereditary  character  of 
certain  degenerative  affections  of  the  nervous  system,  muscles,  and 
epidermal  appendages,  presenting  similar  characteristics  to  the  eye 
affections  dealt  with  in  this  paper,  to  want  of  vital  force  in  the  struc- 
tures involved,  so  that  they  are  unable  to  maintain  their  nutrition  be- 
yond full  development  and,  therefore,  gradually  fail  and  degenerate. 
They  fail,  as  he  says,  "from  imperfect  life,  from  abiosis,  in  what  may 
be  designated  abiotic  atrophy,  or  abiotrophy. " 

He  points  out  that,  "besides  general  life,  the  termination  of  which 
involves  that  of  every  part  of  the  body,  many  of  these  parts  have 
their  own  vitality.  Some  of  them  slowly  die,  while  the  life  of  all  the 
rest  goes  on  without  impairment.  They  die  from  many  causes — some 
early,  inevitably,  from  a  very  grave  defect  of  vital  endurance;  some 
much  later,  the  failure  being  but  slightly  premature;  and  some  at 
various  times,  apparently  from  various  causes.  When  the  failure  is 
early,  it  is  often  due  purely  to  a  defect  in  vitality,  a  defect  which  seems 
to  be  inherent,  the  tendency  thereto  inborn.  We  do  not,  indeed,  apply 
the  word  '  death '  to  this  slow  decay  of  the  elements ;  we  speak  of  it 
as  'degeneration,'  but  the  process  is  in  many  cases,  perhaps  in  most, 
an  essential  failure  of  vitality,  and  I  think  it  is  instructive  to  consider 
the  degeneration  in  this  aspect. " 


Hereditary  Ocular  Degenerations  105 

The  term  vital  force,  in  the  way  in  which  it  is  here  used,  may  be  de- 
fined as  "a  force  the  possession  of  which  differentiates  living  from 
dead  matter. "  Though  we  know  little  as  to  its  real  nature,  it  is  con- 
venient to  have  a  name  to  apply  to  it,  just  as  in  algebra  we  use  a  sym- 
bol to  represent  an  unknown  quantity.  This  vital  force,  as  we  know 
it,  exists  only  in  connection  with  cell  protoplasm,  and  manifests  it- 
self by  what  we  term  irritability.  For  its  maintenance,  the  cells 
possessing  it  require  the  capacity  of  taking  up  certain  substances  from 
the  fluid  media  surrounding  them,  and  of  discharging  other  waste 
products — a  process  probably  capable  of  a  physicochemical  explana- 
tion. 

In  fission  fungi  and  many  unicellular  protozoa  the  vital  force  may 
apparently  be  indefinitely  prolonged,  for  these  simply  formed  organ- 
isms multiply  by  division,  so  becoming  transformed  into  two  new  in- 
dividuals without  leaving  any  corpse  behind. 

In  a  germ  cell  of  multicellular  organisms,  as  the  result  of  fertiliza- 
tion, the  vital  force,  instead  of  becoming  gradually  exhausted  and 
leading  to  degeneration  and  death  of  the  cell,  regains  fresh  vigor, 
causing  it  to  multiply,  develop,  and  evolve  into  a  new  being. 

In  the  cells  of  multicellular  organisms,  which  have  become  much 
differentiated  from  germ  cells,  and  have  acquired  new  and  highly 
specialized  functions,  the  vital  force  is  always  in  a  state  of  transition. 
These  cells  are  always  either  in  a  state  of  evolution  to  maturity  or  in 
a  state  of  involution  to  decay.  At  times  the  process  is  so  slow  that  it 
might  almost  be  thought  that  no  change  was  taking  place,  but  slow 
though  it  be,  and  minute  the  alterations  that  occur,  it  surely  and 
steadily  goes  on.  "  For  so  we  ripe  and  ripe  and  then  we  rot  and  rot. " 

The  time  required  for  the  vital  force  to  complete  the  cycle  of  changes 
which  take  place  from  birth  to  death  varies  considerably  in  different 
species  of  animals,  in  different  individuals  of  the  same  species,  and 
physiologically  in  the  several  tissues  of  which  an  animal  is  composed. 

Among  mammals  the  vital  force  is  of  much  longer  duration  in  ele- 
phants and  man  than  in  horses  and  dogs.  Among  birds  it  is  of  much 
longer  duration  in  parrots  and  geese  than  in  fowls  and  thrushes.  In 
the  tortoise  it  is  of  longer  duration  than  in  any  other  vertebrata,  one 
such  animal  is  estimated  to  have  lived  for  two  hundred  years. 

Among  human  beings  longevity  is  frequently  found  to  be  a  family 
characteristic.  Here  are  three  examples :  Mrs.  Amelia  Spurgeon,  the 
aunt  of  the  great  preacher,  recently  passed  her  one  hundred  and  sec- 
ond birthday.  Her  mother  lived  to  ninety,  and  her  brother  and  two 


106  E.  TREACHER  COLLINS 

sisters  all  passed  the  eighties.  In  a  recent  copy  of  a  daily  paper  there 
was  an  account  of  an  octogenarian,  a  Mr.  Gibbins,  who  had  eight 
brothers  and  sisters,  not  one  of  whom  died  before  reaching  the  age  of 
eighty. 

Thomas  Parr,  who  was  born  in  Shropshire  in  1483,  is  reported  to 
have  reached  the  age  of  one  hundred  and  fifty-two,  and  was  buried 
in  Westminster  Abbey.  The  celebrated  Harvey  examined  his  body 
after  death  and  was  unable  to  discover  any  organic  disease.  Parr  did 
not  marry  until  the  age  of  eighty-eight ;  he  had  a  son  who  lived  until 
the  age  of  one  hundred  and  twenty-seven. 

Physiologically,  in  the  human  body,  the  vital  force  fails  sooner  in 
some  tissues  than  in  others,  e.  g.,  the  thymus  gland  is  highly  developed 
during  fetal  life,  reaches  its  maximum  size  during  the  third  year  of 
life,  and  shows  signs  of  degeneration  which  rapidly  progress  after  the 
age  of  ten.  Other  early  physiologic  failures  of  vital  force,  with  which 
most  of  us  are  unfortunately  only  too  familiar,  are  touchingly  alluded 
to  in  the  following  verse  from  W.  S.  Gilbert's  comic  opera  of  "Pa- 
tience": 

Silvered  is  the  raven  hair, 

Spreading  is  the  parting  straight, 
Mottled  the  complexion  fair, 

Halting  is  the  youthful  gait: 
Hollow  is  the  laughter  free, 
Spectacled  the  limpid  eye, 
Little  will  be  left  of  me, 
In  the  coming  by-and  by. 

As  Sir  James  Paget3  wrote  in  his  famous  Lectures  on  Pathology: 
"It  is  natural  to  become  feeble  and  infirm,  to  wither  and  shrivel,  to 
have  dry,  dusky,  wrinkled  skins,  and  greasy,  brittle  bones,  to  have 
weak,  fatty  hearts,  blackened,  inelastic  lungs,  and  dusky  thin  stomachs, 
and  to  have  every  function  of  life  discharged  feebly,  and  as  it  were 
wearily;  and  then,  with  powers  gradually  decreasing,  to  come  to  a 
time  when  all  the  functions  of  bodily  life  ceasing  to  be  discharged, 
death,  without  pain  or  distress,  ensues."  He  goes  on  to  say  that 
such  a  death  is  rare,  and  that  he  has  only  seen  two  or  three  such  cases. 

In  other  words,  our  bodies  are  not  constructed  like  "The  Deacon's 
Masterpiece;  or  the  Wonderful  One-Hoss  Shay, "  described  by  Oliver 
Wendell  Holmes: 

"That  was  built  in  such  a  logical  way, 
It  ran  a  hundred  years  to  a  day. " 


Hereditary  Ocular  Degenerations  107 

and  then : 

"went  to  pieces  all  at  once, — 
All  at  once  and  nothing  first, — 
Just  as  the  bubbles  do  when  they  burst. " 

To  again  quote  Sir  James  Paget;  he  says :  "The  changes  of  natural 
degeneration  in  advanced  life  have  a  direct  importance  in  all  pathol- 
ogy, because  they  may  guide  us  to  the  interpretation  of  many  similar 
anomalies  which,  while  they  occur  in  earlier  life,  we  are  apt  to  call 
diseases,  but  which  are  only  premature  degenerations,  and  are  to  be 
considered,  therefore,  as  methods  of  atrophy — as  defects,  rather  than 
as  perversions,  of  the  nutritive  process — or  as  diseases  only  in  consid- 
eration of  the  time  of  their  occurrence."  This  was  written  in  1853, 
and  it  is  an  interesting  anticipation  of  Sir  William  Gowers '  theory  of 
"  Abiotrophy, "  or  degeneration  of  tissues  due  to  defective  vitality. 

Metchnikoff 4  would  have  us  believe  that  the  symptoms  we  speak  of 
as  senile  degeneration  are  not  a  natural  sequence  of  life,  ushering  in 
its  close,  but  the  outcome  of  auto-intoxication.  In  his  writings, 
however,  he  frequently  speaks  of  "the  cycle  of  life"  and  of  "natural 
death,"  which  latter  he  defines  as  a  "phenomenon  that  is  intrinsic  in 
the  nature  of  an  organism  and  not  the  mere  result  of  an  external  acci- 
dent. "  What  apparently  he  does  not  recognize  is  that  the  cycle  of  life 
may  be  of  variable  duration  in  the  different  tissues  of  an  individual, 
and  the  intrinsic  phenomenon,  "natural  death,"  may  take  place 
sooner  in  some  cells  of  the  body  than  in  others.  Doubtless  some 
tissues  in  which  the  cycle  is  drawing  to  a  close  are  likely  to  succumb 
to  some  toxic  influence  earlier  than  they  otherwise  would,  in  which 
case  the  change  produced  might  be  attributed  entirely  to  the  toxin,  the 
weakened  resistance  power  of  the  tissue  having  been  overlooked. 

It  is  as  unreasonable  to  attribute  all  variations  in  the  time  of  degen- 
eration of  tissues  to  toxic  influences  as  it  would  be.to  account  for  all 
variations  in  the  time  of  development  of  tissues  to  such  influences. 
Just  as  we  sometimes  meet  with  precociousness  in  development,  so 
sometimes  we  meet  with  precociousness  in  degeneration.  It  is  with 
some  of  the  precocious  degenerations  of  the  tissues  of  the  eye  that  I 
now  proceed  to  deal. 


HEREDITARY  POST-NATAL  CATARACT  OR  ABIOTIC  CATARACT 
Under  the  heading  of  cutaneous  abiotrophy  Sir  William  Gowers1 
described  the  early  baldness  met  with  in  the  males  of  the  family  in 


108  E.  TREACHER  COLLINS 

several  successive  generations,  the  essential  cause  of  which  is  the 
failure  of  the  life  of  the  hair-follicles  of  the  scalp.  He  also  spoke  of 
early  grayness  of  the  hair  as  a  qualitative  failure,  an  enduring  defect 
of  one  function  of  the  follicles. 

Another  very  common  form  of  degeneration  met  with  in  a  structure 
derived  from  cuticular  epiblast  is  opacity  of  the  lens  of  the  eye,  the 
outcome  of  a  premature  failure  in  the  vitality  of  its  fibers,  a  condition 
which  may,  I  suggest,  be  aptly  termed  abiotic  cataract. 

That  these  changes  are  due  to  defective  vitality  is  shown  by  their 
inherent  character.  Nettleship 5  states  that :  "  Post-natal  or  acquired 
cataract  is  often  hereditary,  and  quite  a  number  of  pedigrees  have 
been  collected  by  many  observers. " 

Such  post-natal  cataracts  have  been  described  according  to  age  of 
onset  as  "senile,"  "presenile, "  and  "juvenile."  But,  as  Nettleship 
says:  "This  subdivision  is,  no  doubt,  arbitrary,  and  does  not  corre- 
spond with  any  differences  in  the  cause  or  character  of  the  cataract, 
but  is  of  some  practical  convenience." 

He  collected  and  analyzed  a  large  number  of  pedigrees  of  post-natal 
cataract,  and,  commenting  on  the  age  of  onset,  remarked:  "In  one 
and  the  same  family  hereditary  cataract  often  begins  at  about  the 
same,  age  in  all  who  have  it.  But  exceptions  to  this  are  very  numer- 
ous for,  as  we  have  just  seen,  hereditary  cataract  often  occurs  at  an 
earlier  age  in  the  children  than  in  the  parents,  whilst  in  those  of  the 
same  generation  it  frequently  begins  at  about  the  same  age  in  each." 

In  1917  I  operated  for  cataract  at  the  Moorfields  Hospital  on  two 
members  of  a  family  of  seven.  The  five  other  members  of  the  family 
and  their  father  had  previously  been  operated  on  for  cataract  at  the 
same  hospital.  These  facts  I  was  able  to  verify  by  reference  to  the 
in-patient  notes.  I  was  further  told  that  my  patient's  two  paternal 
uncles  had  been  operated  on  for  cataract,  one  at  St.  Thomas '  Hospital 
and  the  other  at  Cardiff.  Of  the  family  of  seven  two  were  males  and 
five  females.  Their  ages  at  the  time  they  were-operated  on  were  as 
follows:  forty-two,  fifty-six,  forty-nine,  sixty-three,  fifty-six,  fifty- 
eight.  The  age  of  their  father  at  the  time  of  operation  was  sixty. 

In  a  family  such  as  this,  in  which  so  large  a  number  of  its  members 
became  affected  with  early  senile  cataract,  it  seems  necessary  to 
assume  some  inherent  defect  in  the  vitality  of  the  lens-fibers  which 
results  in  their  degeneration. 

To  speak  of  certain  forms  of  post-natal  cataract  as  abiotic  does  more 
than  simply  describe  them  as  due  to  degeneration.  I  propose  to  show 


Hereditary  Ocular  Degenerations  109 

that  it  enables  us  to  understand  their  pathology  more  clearly  than  has 
previously  been  possible. 

In  considering  the  degenerative  processes  which  occur  in  the  struc- 
ture of  the  lens  it  is  first  necessary  to  recognize  that  there  is  a  physio- 
logic degeneration  constantly  taking  place  in  its  fibers  which  does  not 
result  in  the  formation  of  opacity,  and  which,  in  an  anteroposterior 
section  of  an  adult  lens,  can  be  seen  in  all  its  stages  in  passing  from 
the  periphery  to  the  nucleus. 

Newly  formed  lens-fibers,  such  as  are  seen  close  to  the  capsule,  form 
long  flat  bands  with  regular  margins,  rounded  or  hexagonal  in  trans- 
verse section,  and  containing  rounded  or  elliptic  well-staining  nuclei. 
Older  fibers,  further  from  the  capsule,  become  denser  and  flatter;  their 
nuclei  show  at  first  an  aggregation  of  chromatin  toward  the  periph- 
ery, and  later  disappear  altogether,  clear  oval  spaces  being  left  at 
the  sites  they  occupied,  which,  in  still  older  fibers,  also  disappear. 
The  oldest  fibers  of  all,  those  in  the  center  of  the  lens,  are  harder  and 
more  condensed.  They  have  crenated  margins,  the  projections  and  in- 
dentations of  which  fit  tightly  into  one  another,  and  they  are  entirely 
devoid  of  any  trace  of  nuclei.  This  gradual  hardening  of  the  lens- 
fibers  is  spoken  of  as  sclerosis. 

In  pathologic  degeneration  of  the  lens,  such  as  is  met  with  in  senile 
cataracts,  the  first  change  observed  is  the  formation  of  clefts  between 
the  fibers  in  its  peripheral  parts.  In  these  clefts  the  interfibrillar  fluid 
accumulates,  and  in  hardened  sections  of  the  lens  presents  the  appear- 
ance of  irregularly  shaped,  coagulated  masses,  or  of  spheroidal  bodies, 
the  so-called  Morgagnian  globules.  The  formation  of  these  clefts  is 
usually  attributed  to  an  excess  of  the  physiologic  shrinking  of  the  nu- 
cleus of  the  lens.  In  the  adult  lens,  and  to  a  larger  extent  in  the  senile 
lens,  the  nucleus  is  quite  hard,  due  to  the  physiologic  shrinking  and  de- 
generation which  have  taken  place  in  its  fibers..  It  seems  difficult  to 
understand  how  there  can  be  any  increase  in  the  physiologic  shrinking 
of  this  already  horny,  sclerosed  part  of  the  lens.  The  region  in  which 
the  clefts  are  formed  and  where  the  opacity  begins  is  where  the  lens- 
fibers  have  not,  in  the  normal  state,  undergone  much  shrinking  or  de- 
generation; and  regarding  the  condition  as  due  to  abiotrophy,  it 
would  be  natural  to  assume  that  the  clefts  are  due  to  a  premature 
shrinking  and  degeneration  of  what  should  be  well-nourished  fibers, 
rather  than  changes  in  a  part  of  the  lens  where  metabolic  processes  are 
practically  at  a  standstill.  Though  the  lens-fibers  bounding  the  clefts 
at  first  show  but  little  change  beyond  some  condensation  of  their  sub- 


110  E.  TREACHER  COLLINS 

stance,  such  as  is  met  in  the  physiologic  degeneration  process,  later  on 
their  substance  becomes  granular,  fatty  globules  may  form  in  them, 
and  they  break  down  into  the  spaces  formed  between  them  by  their 
shrinkage,  and  thus  the  cataractous  process  progresses. 


HEREDITARY  OCULAR  PALSIES.  ABIOTROPHY  OF  THE  MUSCLES  OF 
THE  EYELIDS  AND  EYEBALLS 

In  discussing  the  various  forms  of  hereditary  paresis  of  the  muscles 
of  the  eyes  and  eyelids  it  will  be  well  first  to  quote  some  of  Gowers' x 
remarks  on  muscular  abiotrophy  in  general.  In  his  first  lecture  on 
the  subject  he  wrote  as  follows: 

"In  the  various  forms  of  idiopathic  muscular  atrophy,  in  which 
there  is  a  primary  atrophy  of  the  muscular  fibers,  we  have  examples  of 
a  true  abiosis.  To  all  these  primary  myopathies  it  has  become  custom- 
ary to  apply  the  term  'muscular  dystrophy,'  and  the  custom  is  con- 
venient, if  not  quite  accurate.  The  term  thus  includes  both  simple 
muscular  atrophy  and  its  well-known  congener,  pseudohy  per  trophic 
paralysis.  In  these  the  muscle-fibers,  after  full  development,  cease  to 
maintain  their  nutrition.  They  slowly  waste,  and  a  large  number — 
most  of  them  in  many  parts,  all  in  some — -perish.  The  connective 
tissue  between  them  overgrows.  Its  increase  may  fail  to  maintain  the 
normal  bulk  of  the  muscles,  so  that  they  waste  conspicuously,  some- 
times extremely.  In  other  cases  this  tissue-weed,  as  we  may  regard  it, 
presents  a  more  luxuriant  development,  and  produces  fat-bearing  cells 
which  so  much  increase  the  bulk  of  the  muscle  as  to  cause  the  enlarge- 
ment of  pseudohypertrophy. " 

In  another  lecture2  on  the  same  subject  he  wrote: 

"The  nutrition  of  the  muscle  depends  on  that  of  the  nerves  through 
which  its  function  is  called  forth.  If  the  nerves  slowly  degenerate, 
so  does  the  muscle;  if  .rapidly,  from  descending  irritation,  the  muscles 
undergo  speedy  complete  degeneration.  Yet  the  muscle  has  a  life 
which  we  may  call  organic,  belonging  to  it  as  a  structural  entity,  in 
consequence  of  which  it  may  undergo  morbid  changes,  apart  from  the 
nervous  system,  and  may  fail  to  live  on,  though  the  nerves  preserve  an 
unimpaired  vitality.  This  failure  is  what  I  have  called  muscular 
abiotrophy — failure  of  nutrition  from  defective  vitality — and  for 
brevity  we  call  it  myopathy. " 

Among  the  muscular  abiotrophies  which  he  thus  defines  he  includes 
the  " f acio-scapulo-humeral  type,"  also  designated  the  "type  of 
Landouzy-De'je'rine. "  In  this  affection  there  is  extreme  wasting  of 


Hereditary  Ocular  Degenerations  111 

the  muscles  picked  out,  including  the  orbicularis  palpebrarum.  No 
matter  how  long  the  duration  of  the  malady,  it  seems  to  remain  purely 
muscular,  the  nervous  system,  even  the  motor  nerves,  remaining  un- 
changed. It  is  a  family  and  hereditary  disease,  and  may  be  trans- 
mitted by  either  male  or  female  parent;  it  affects  both  boys  and 
girls  alike. 

In  1915  I  showed6  a  girl,  aged  seven,  who  had  bilateral  facial 
paralysis.  At  that  time  there  was  no  affection  of  the  muscles  of  the 
shoulder-girdle,  though  there  was  some  paralysis  of  the  extensor 
muscles  of  the  leg,  causing  her  to  walk  with  a  peculiar  gait,  her  toes 
turning  inward.  She  had  the  typical  expressionless,  so-called  myo- 
pathic,  face.  She  was  unable  to  close  her  eyes  from  paralysis  of  the 
orbicularis  muscles,  and  her  lower  lids  fell  a  little  away  from  the  eye- 
balls, causing  epiphora.  There  were  no  symptoms  pointing  to  any 
involvement  of  the  nervous  system,  and  the  case  appeared  to  be  one 
of  purely  muscular  atrophy. 

Fuchs7  in  1890  reported  five  cases  in  which  bilateral  ptosis  was  the 
only  symptom  of  disease.  In  two  of  them,  aged  thirty  and  sixty  re- 
spectively, the  ptosis  appeared  early  in  life,  was  hereditary,  and  in 
course  of  time  became  complete.  The  other  three,  aged  forty,  sixty, 
and  fifty-six  years  respectively,  developed  ptosis  late  in  life;  it  slowly 
increased  and  became  almost  complete.  There  was  no  history  of 
syphilis  in  these  cases,  and  no  evidence  of  brain  disease.  The  upper 
eyelids  were  thinned  to  such  an  extent  that  the  anterior  parts  of  the 
eyeball  showed  plainly  through  them.  There  was  also  shrinking  of 
the  orbital  fat  in  the  immediate  vicinity  of  the  levator,  as  shown  by 
falling  in  of  the  lid  just  below  the  orbital  rim.  Fuchs  removed  and 
examined  a  small  portion,  of  the  muscle  in  one  of  his  cases,  and  found 
the  fibers  much  thinner  than  those  from  a  healthy  muscle ;  the  nuclei 
were  considerably  increased  in  number,  and  there  was  marked  pigmen- 
tary degeneration  inside  the  sarcolemma  but  no  fatty  degeneration 
was  found.  In  some  parts  the  fibers  themselves  appeared  normal  in 
structure,  the  connective  tissue  between  them  being,  however,  in- 
creased in  amount.  Fuchs  was  of  opinion  that  his  cases  were  best  ex- 
plained by  a  primary  atrophy  confined  to  the  levator  palpebrae 
muscles,  an  affection  which,  up  to  that  time,  had  not  been  described. 

In  1909  I  published  the  notes8  of  what  I  took  to  be  a  similar  case  to 
those  described  by  Fuchs  of  bilateral  ptosis,  unaccompanied  by  paraly- 
sis of  any  other  muscles.  Like  all  Fuchs'  cases,  the  patient  was  a 
female,  and  like  some  of  his  cases,  there  was  a  slight  amount  of  ptosis, 


112  E.  TREACHER  COLLINS 

dating  either  from  birth  or  from  early  infancy.  That  the  ptosis  had 
steadily  increased  was  well  shown  by  the  examination  of  a  series  of 
photographs  she  had  had  taken  at  different  ages.  At  the  time  she 
came  under  my  observation  she  was  sixty-nine  years  old.  She  also 
had  a  very  unusual  circumferential  encroachment  by  the  limbus  of 
the  conjunctiva  on  to  the  cornea  in  the  two  eyes.  I  cut  away  a  strip  of 
the  levator  palpebrae  muscle  in  each  eye,  as  Fuchs  did,  and  found  it 
very  atrophic ;  unfortunately,  I  did  not  have  it  examined  microscop- 
ically. 

In  1900  W.  M.  Beaumont  published9  the  account  of  a  family  in 
which  several  members  of  four  different  generations  suffered  from 
ophthalmoplegia  externa.  The  disease  was  never  congenital,  but  al- 
ways appeared  in  adult  life;  it  was  slowly  progressive,  and  never  ap- 
pears to  have  had  a  fatal  termination.  The  characteristics  of  the 
members  of  the  family  were  to  enjoy  a  long  life  and  to  have  troops  of 
children.  The  cases,  most  fully  examined,  showed  complete  paralysis 
of  the  levator  palpebrae  on  each  side,  and  very  limited  action  of  the 
recti  muscles  in  any  direction.  In  one  case  it  was  noted  that  the 
action  of  the  orbicularis  muscle  was  very  feeble.  In  none  of  the 
cases  were  the  intra-ocular  muscles  involved. 

McMullen  and  Hine,10  in  a  recent  paper  on  chronic  progressive 
ophthalmoplegia  externa,  mention  that:  "Wilbrand  and  Saenger11 
grouped  as  a  clinical  entity  certain  cases  of  external  ophthalmoplegia, 
which,  in  their  opinion,  had  definite  characteristics,  which  separated 
them  not  only  from  the  congenital  cases  of  this  affection,  but  also 
from  the  cases  definitely  due  to  some  toxic  cause  or  to  syphilis,  or  as- 
sociated with  wider  spread  manifestations  of  nervous  disease. "  These 
cases,  according  to  these  authors,  have  the  following  characteristics: 
''There  is  a  gradual  onset,  generally  in  infancy  or  early  childhood, 
more  rarely  in  later  life,  of  a  bilateral,  progressive  paralysis  of  the  ex- 
ternal eye  muscles,  not  associated  with  other  signs  of  disorder  of  the 
nervous  system  nor  with  fever.  The  disease  may  come  to  a  standstill 
permanently,  or  for  long  periods,  at  any  stage  of  its  development,  but 
generally  ends  in  complete,  or  nearly  complete,  external  ophthalmo- 
plegia. In  most  cases  both  sides  are  affected  from  the  beginning,  but 
sometimes  it  appears  on  one  side  long  before  the  other;  often  the  two 
sides  are  unequally  affected  in  the  early  stages.  Ptosis  is  generally 
the  first  sign,  and  may  be  for  a  long  time  the  only  one.  When  the 
muscles  of  the  eyeball  become  affected,  diplopia  may  be  complained  of, 
but  this  symptom  is  only  rarely  noted,  principally  because  the  paraly- 


Hereditary  Ocular  Degenerations  113 

sis  develops  gradually,  and  often  symmetrically,  on  both  sides,  and 
because  it  frequently  comes  on  in  childhood  before  the  function  of 
binocular  vision  is  fully  developed.  The  progress  is  often  extremely 
slow,  and  thirty  or  forty  years  may  elapse  between  the  appearance  of 
the  first  symptoms  and  the  development  of  complete  ophthalmoplegia. 
The  general  health  is  not  affected,  and  there  is  a  noteworthy  absence 
of  signs  indicating  disease  in  other  parts  of  the  nervous  system. " 

Wilbrand  and  Saenger  n  collected  records  of  32  cases  of  this  affection. 
McMullen  and  Hine,  in  their  article,  refer  to  two  others  described 
by  Ayres12  and  Altland,13  and  give  notes  of  three  of  their  own.  In 
Ayres '  case  the  maternal  grandfather  of  the  patient  was  said  to  have 
been  similarly  affected.  The  following  case,  evidently  belonging  to 
the  same  class,  has  recently  come  under  my  observation: 

Frederick  R.,  aged  forty-three,  stated  that  his  eyelids  began  to  droop 
twenty-eight  years  previously,  and  that  shortly  afterward  he  was  operated 
on  for  it  by  Mr.  Lawford.  His  condition  was  improved,  but  the  drooping  had 
persisted.  He  came  to  me  on  account  of  some  conjunctivitis  in  one  of  his 
eyes,  and  I  then  discovered  that,  in  addition  to  bilateral  ptosis  of  a  very 
marked  degree,  he  also  had  ophthalmoplegia  externa.  He  had  only  very 
slight  power  of  movement  of  either  eye  laterally  or  vertically,  and  practically 
no  rotatory  movement.  His  pupils  were  equal  and  active,  and  he  had  no 
more  defect  of  accommodation  than  such  as  might  be  expected  in  a  man  of 
his  age  with  a  slight  degree  of  hypermetropia.  His  occupation  was  a  carman  > 
he  had  never  experienced  any  diplopia,  or  found  any  difficulty  in  driving 
about  the  crowded  streets  of  London.  He  has  six  children — none  of  them  or, 
so  far  as  he  knows,  any  other  member  of  his  family  has  suffered  from  an 
affection  of  the  eyes  similar  to  his.  He  is  a  strong,  healthy  man,  shows  no 
sign  of  any  affection  of  his  nervous  system.  His  Wassermann  reaction  was 
tested  and  found  negative. 

In  discussing  these  cases  it  is  first  necessary  to  draw  a  distinction  be- 
tween them  and  cases  of  congenital  defect  in  the  movements  of  the 
eyeballs  and  eyelids,  a  class  of  cases  dealt  with  very  fully  by  G.  Heuck14 
in  1879,  and  by  Lawford15  in  1888.  The  former  found,  by  post- 
mortem examinations,  that  in  these  congenital  cases  the  defect  of 
movement  was  due  either  to  absence  of  the  muscle,  its  imperfect  de- 
velopment, its  insufficient  length,  or  its  faulty  attachment  to  the  eye- 
ball. In  the  class  of  cases  here  under  consideration  there  has  for  a 
time  been  good  movement  of  the  eyelids  and  eyeballs,  and  then 
gradual  and  progressive  failure  has  set  in.  In  the  one  there  is  from 
8 


114  E.  TREACHER  COLLINS 

the  first  a  defect  of  development,  in  the  other  degeneration  sets  in 
after  full  development. 

Most  writers  on  these  hereditary  ocular  palsies,  and  on  the  cases 
presenting  similar  symptoms  which  arise  sporadically,  regard  them 
as  due  to  lesions  in  the  nuclei  of  the  nerves  supplying  the  affected 
muscles.  It  is,  however,  possible  that  the  primary  condition  may  be 
a  degeneration  of  the  muscle-fibers  and  that  the  nerves  supplying  them 
may  be  unaffected.  Whichever  be  the  true  explanation,  seeing  that 
the  affection  is  in  some  instances  a  hereditary  one,  and  that  it  is  not 
due  to  syphilis,  it  may  appropriately  be  regarded  as  of  an  abiotic 
nature — either  an  abiotrophy  of  the  cells  of  the  nerve  nuclei,  or  an 
abiotrophy  of  the  muscle-fibers. 

The  assistance  which  might  be  obtained  by  examination  of  the 
electric  reactions  in  these  cases  to  determine  the  nature  of  the  muscu- 
lar weakness  is  not  available.  The  exact  primary  nature  can  cer- 
tainly be  decided  only  by  postmortem  examination,  but  up  to  the 
present  no  such  examinations  have  been  carried  out. 

The  order  in  which  the  different  series  of  paralytic  affections  of  the 
muscles  of  the  eyelids  and  eyeball  are  referred  to  above  has  been 
arranged  with  a  purpose.  The  first-mentioned  were  cases  of  the  facio- 
scapulo-humeral  type,  in  which  there  was  inability  to  close  the  eyes 
from  paralysis  of  the  orbicularis  palpebrarum  muscle;  and  then  a 
case  of  bilateral  facial  paralysis  without  any  affection  of  the  muscles 
of  the  shoulder-girdle.  These  cases  are  undoubtedly  of  a  myopathic 
nature.  Next,  Fuchs'  cases  of  bilateral  ptosis  were  quoted,  some  of 
which  were  hereditary;  these  he  regarded  as  due  to  primary  atrophy 
of  the  muscles,  a  view  which  received  support  from  the  appearance  of 
a  strip  of  one  of  the  affected  muscles  examined  microscopically. 
Following  on  these  Beaumont 's  family,  with  ophthalmoplegia  in  four 
different  generations,  was  described.  In  one  member  of  the  family, 
in  addition  to  the  ophthalmoplegia,  there  was  some  paresis  of  the  or- 
bicularis palpebrarum  muscle.  Finally  came  the  group  of  cases  sep- 
arated off  as  a  clinical  entity  by  Wilbrand  and  Saenger,  in  which  there 
was  chronic  progressive  bilateral  paralysis  of  all  the  orbital  striated 
muscles,  the  unstriated  intra-ocular  muscles  invariably  remaining  un- 
affected. In  this  group  the  muscles  affected  are  never  confined  to 
those  supplied  from  one  nerve  nucleus,  and  the  paresis  of  some  of  the 
muscles  often  remains  for  a  long  time  incomplete.  Many  of  the  cases 
in  this  group  have  been  watched  for  prolonged  periods  without  de- 
veloping any  symptoms  due  to  disturbances  of  the  nervous  system. 


Hereditary  Ocular  Degenerations  115 

These  facts  taken  together  offer,  I  suggest,  strong  circumstantial 
evidence  in  favor  of  the  view  that  cases  of  bilateral  ophthalmoplegia, 
like  cases  of  bilateral  facial  paralysis  and  cases  of  bilateral  ptosis,  are 
due  to  a  primary  degeneration  in  the  muscle-fibers. 


"RETINITIS  PIGMENTOSA"  OR  ABIOTROPHY  OF  THE  RETINAL  NEURO- 

EPITHELIUM 

In  a  paper  published  in  1919 16  I  collected  together  a  considerable 
amount  of  evidence  to  show  that  the  affection  commonly  known  as 
retinitis  pigmentosa  should  really  be  regarded  as  a  primary  degenera- 
tion, or  abiotrophy,  of  the  neuro-epithelium  of  the  retina.  It  will  be 
here  only  necessary  to  summarize  the  evidence  set  out  in  that  paper. 

Nettleship,17  in  1907,  made  a  most  comprehensive  collection  of  all 
the  data  concerning  retinitis  pigmentosa  then  available,  and  described 
the  disease  as  "the  result  of  a  tissue  liability  present,  though  seldom 
manifest,  at  birth,  and  known  to  be  so  often  hereditary  that  we  may 
be  sure  it  is  so  also  in  many  cases  where  the  proof  is  wanting." 

Wagenmann18  showed,  by  division  of  one  of  the  posterior  ciliary 
arteries  in  animal  eyes,  that  the  nutrition  of  the  outer  layers  of  the 
retina  depend  on  the  choroidal  circulation.  In  the  area  supplied  by 
the  divided  vessel  both  choroid  and  retina  atrophied,  the  latter  be- 
coming adherent  to  the  former  and  also  pigmented. 

Frequently  after  sclerosis  of  the  choroidal  vessels,  due  either  to 
syphilis  or  to  senility,  pigmentation  of  the  retina  is  observed.  From 
this,  and  from  Wagenmann 's  experiments,  it  had  been  inferred  that 
the  pigmentation  of  the  retina  in  retinitis  pigmentosa  is  also  due  to 
sclerosis  of  the  choroidal  vessels.  Pathologic  examinations  of  eyes  in 
cases  of  retinitis  pigmentosa,  at  different  stages  of  the  disease,  and 
made  by  different  observers,  have  shown  it  may  occur  without  any 
such  thickening  of  the  choroidal  vessels  being  present. 

W.  T.  Lister,19  in  1903,  examined  the  eyes  of  a  man  who  died  at  the 
age  of  sixty,  who,  at  the  age  of  thirty-eight,  had  been  found  by  Nettle- 
ship  to  have  advanced  retinitis  pigmentosa.  Lister  found  that  though 
the  choriocapillaris  was  atrophied,  the  choroidal  vessels  seen  in  section 
showed  no  thickening  of  their  walls.  The  layer  of  rods  and  cones  was 
altogether  absent,  its  place  being  taken  by  laminated  fibrous  tissue. 

Stock,20  in  1908,  examined  microscopically  an  eye  with  typical 
retinitis  pigmentosa,  excised  during  life  for  an  adjacent  carcinoma, 
and  fixed  immediately  in  Zenker's  fluid.  He  found  a  practically 
normal  choroid.  The  primary  changes  appeared  to  be  a  degenera- 


116  E  TREACHER  COLLINS 

tion  of  the  bacillary  layer  of  the  retina,  followed  by  degeneration  of 
its  nervous  elements  and  disturbance  of  the  pigment  epithelium. 

Ginsberg,21  in  1908,  examined  histologically  the  eyes  of  a  man 
known  to  have  had  retinitis  pigmentosa  for  ten  years,  who  died  of  tu- 
berculosis at  the  age  of  thirty-five  years.  The  vascular  system  of  the 
choroids  in  these  eyes  showed  no  changes.  The  outer  layers  of  the 
retinae  were  the  parts  most  affected,  the  neuro-epithelium  being  almost 
entirely  destroyed.  He  suggested  that  its  degeneration  was  due  to  a 
congenital  weakness  in  the  standard  of  functional  activity  imparted 
to  these  cells,  so  that  they  had  not  grown  in  proportion  to  the  de- 
mands made  upon  them  and  therefore  gradually  disintegrated;  i.  e., 
to  abiotrophy. 

Suganama,22  in  1912,  examined  microscopically  the  eye  of  a  man, 
aged  sixty-seven,  with  typical  retinitis  pigmentosa,  removed  on  ac- 
count of  a  hypopyon  ulcer.  There  was  no  sclerosis  of  the  choroidal 
vessels  and  the  choriocapillaris  was  normal,  except  in  a  few  areas  where 
it  was  absent  or  imperfect.  There  was  complete  absence  of  the  rods 
and  cones.  The  retinal  nervous  elements  were  atrophic,  and  the 
neuroglia  had  proliferated. 

The  evidence  afforded  by  these  pathologic  investigations  seems 
conclusively  to  show  that  retinitis  pigmentosa  may  arise  and  exist  for 
many  years  unaccompanied  by  any  thickening  of  the  choroidal  vessels. 
Further,  that  the  disease  starts  in  the  retinal  neuro-epithelium,  which, 
having  attained  its  full  normal  development,  then  degenerates.  As  it 
is  a  hereditary  condition,  this  tendency  to  degenerate  must  be  due  to 
some  inherent  weakness  in  the  affected  cells. 

Atrophy  of  the  percipient  elements  in  a  sensory  organ  is  necessarily 
followed  by  atrophy  of  the  nervous  elements  in  connection  with  them, 
and  a  decrease  in  the  vascular  supply  to  the  part.  So  in  the  retina  in 
retinitis  pigmentosa,  following  on  the  atrophy  of  the  rods  and  cones, 
there  is  atrophy  of  the  ganglion-cells  and  other  nervous  elements  in 
the  retina,  together  with  a  dwindling  of  the  smaller  blood-vessels  of 
both  the  retinal  and  choroidal  circulations. 

As  often  happens,  when  the  highly  specialized  elements  of  a  struc- 
ture degenerate,  the  less  highly  organized  supporting  framework  of 
the  tissue  tends  to  increase.  It  will  be  well  for  me  to  quote  here  what 
Gowers  l  wrote  of  this  matter  in  connection  with  neuronic  abiotrophy 
of  the  central  nervous  system,  because  it  applies  so  well  to  the  retina 
in  retinitis  pigmentosa.  He  says:  "Whenever  the  nerve  elements 
waste  there  is  always  an  overgrowth  of  the  interstitial  neuroglia,  the 


Hereditary  Ocular  Degenerations  117 

connecting  and  supporting  tissue  which  lies  between  them.  This 
overgrowth  may  be,  indeed,  on  first  inspection,  the  most  conspicuous 
element,  and  its  aspect  has  led  the  progress  to  be  termed  "sclerosis." 
I  say  "its  aspect"  because  there  is  generally  no  increase  of  consistence 
in  the  part  so  changed.  This  is  generally  diminished;  the  interstitial 
tissue,  which  looks  so  fibrous  and  firm  under  the  microscope,  is  really 
softer  than  the  nerve  elements  that  have  perished. 

"The  two  elements,  the  neural  and  the  neuroglial,  seem  to  have  a 
common  but  inverse  vitality;  it  is  in  consequence  of  this  that  the  in- 
terstitial tissue  overgrows  when  the  nerve  elements  decay.  The  over- 
growth seems  to  coincide  with  the  very  commencement  of  the  decay, 
and  may  be  at  first  the  most  conspicuous. 

"It  is  especially  luxuriant  where  the  connective  tissue  is  naturally 
most  abundant — about  the  vessels  and  at  the  surface  of  the  spinal 
cord  beneath  the  pia  mater." 

Having  described  the  pathologic  findings  in  this  disease  I  will  now 
show  how  well  they  help  us  to  explain  the  sequence  of  the  symptoms 
met  with  in  connection  with  it. 

The  first  symptom  a  patient  complains  of  in  retinitis  pigmentosa  is 
night-blindness;  this  precedes  the  appearance  of  any  pigmentation. 
As  Nettleship  17  pointed  out,  the  term  "retinitis  pigmentosa  sine  pig- 
mento"  "usually  signifies  nothing  more  than  the  initial  stage  of  the 
ordinary  disease."  The  part  of  the  retina  first  involved  is  the  peri- 
macular  zone;  a  ring  scotoma  is  found  to  precede  any  contraction  of 
the  periphery  of  the  field.  Pigmentation  of  the  retina  when  it  makes 
its  appearance  is  also  first  seen  in  an  intermediate  zone  between  the 
macula  and  the  periphery.  It  is  not  until  the  later  stages  of  the 
affection  that  the  retinal  blood-vessels  become  narrowed  and  the 
optic  disc  acquires  its  characteristic  waxy  appearance. 

In  the  dark-adapted  eye  the  part  of  the  retina  which  is  most  sensi- 
tive to  light  is  that  surrounding  the  macula.  Experiments  have 
shown  that  its  sensibility  increases  centrifugally  with  each  degree 
until  10°  to  20°  from  the  fovea,  where  the  maximum  is  reached.  On 
the  other  side  of  this  maximum  the  sensibility  decreases  toward  the 
periphery  in  approximately  concentric  circles.  Degeneration  of  the 
percipient  elements  of  the  retina,  in  the  part  most  acutely  sensitive  to 
light,  accounts,  therefore,  for  the  early  occurrence  of  the  night-blind- 
ness. 

In  a  typical  case  of  retinitis  pigmentosa  the  inner  border  of  the  ring 
scotoma  corresponds,  as  a  rule,  to  about  the  15°  or  10°  in  perimeter 


118  E.  TREACHER  COLLINS 

charts.  That  is  to  say,  the  part  of  the  retina  in  which  failure  of 
function  commences  is  that  in  which  its  neuro-epithelium  first  attains 
its  full  development.  The  macular  area,  together  with  the  nerve- 
fibers  proceeding  from  it,  is  both  ontogenetically  and  phylogenetically 
of  late  development. 

Pigmentation  of  the  retina  is  due  to  the  migration  of  pigment  epithe- 
lial cells  into  its  substance.  The  reason  why  it  is  such  a  characteristic 
feature  of  the  disease  we  term  retinitis  pigmentosa  is  that  the  disease 
commences  in  the  rods  and  cones;  the  gaps  left  in  the  membrana 
limitans  externa  by  their  disappearance  form  tracks  through  which 
the  pigment  cells  can  make  their  way.  We  know  that  these  pigment 
epithelial  cells  physiologically  possess  the  power  of  ameboid  move- 
ment. When  stimulated  by  light,  they  throw  out  filamentous  pro- 
cesses between  the  outer  segments  of  the  rods  and  cones,  and  on  re- 
moval of  the  stimulus  retract  these  processes  into  the  body  of  the 
cell.  They  possess  a  capacity  for  positive  phototactic  movement 
which  is  kept  in  check  only  by  their  anatomic  relations ;  when  these 
are  altered  by  the  atrophy  of  the  rods  and  cones,  together  with  the 
nerve  elements  of  the  retina,  so  that  only  a  network  of  neuroglial  tissue 
remains,  then  the  pigment  epithelial  cells,  attracted  forward  by  the 
stimulus  of  light,  are  able  to  make  their  way  into  the  innermost  layers 
of  the  retina,  where  they  accumulate  in  the  lymph-spaces  around  the 
blood-vessels  and  give  rise  to  the  characteristic  branching  patches. 

The  waxy  appearance  of  the  optic  disc  in  retinitis  pigmentosa,  which 
is  different  from  that  met  with  in  any  other  affection,  is  attributable 
to  an  overgrowth  of  its  neuroglia.  In  rare  cases  hyaline  bodies,  some- 
times in  grape-like  clusters,  are  seen  protruding  from  the  surface  of 
the  disc.  In  microscopic  appearance  and  in  their  reaction  to  chemical 
reagents  these  hyaline  bodies  are  found  to  resemble  those  so  commonly 
met  with  on  the  inner  surface  of  the  elastic  lamina  of  the  choroid. 
These  latter  are  due  to  some  perverted  activity  of  the  pigment  cells — 
i.  e.,  cells  which  are  derived  from  the  outer  layer  of  the  secondary 
optic  vesicle.  Cells  having  a  similar  embryonic  origin  are  found  in 
connection  with  supporting  neuroglia  of  the  optic  nerve.  It  would 
seem  probable,  therefore,  that  in  retinitis  pigmentosa,  where  there  is 
an  overgrowth  of  neuroglia  in  the  optic  nerve,  the  hyaline  nodules  met 
with  on  its  surface  are  due  to  some  perverted  activity  of  the  neu- 
roglia cells. 

Retinitis  pigmentosa  is  not  infrequently  associated  with  other 
forms  of  hereditary  degenerative  conditions,  the  commonest  of  these 


Hereditary  Ocular  Degenerations  119 

being  deafness  and  idiocy.  Nettleship  17  estimated  that  33  per  cent, 
of  persons  with  retinitis  pigmentosa  may  be  deaf,  and  at  least  4  per 
cent,  of  deaf-mutes  may  have  retinitis  pigmentosa.  The  deafness  in 
these  cases  is  always  bilateral  and  is  never  recovered  from.  Even 
when  accompanied  by  dumbness  it  may  have  been  acquired,  according 
to  Politzer,  as  late  as  the  age  of  seven  years.  The  pathologic  changes 
found  in  the  labyrinth  of  deaf-mutes  are  comparable  to  those  found 
in  the  retina  in  retinitis  pigmentosa,  and  may  be  summarized  as  de- 
generation of  the  neuro-epithelium,  atrophy  of  the  nerve-fibers,  and  a 
new  formation  of  fibrous  tissue.  'It  is  then  highly  probable  that,  as  in 
retinitis  pigmentosa,  the  affection  being  primarily  a  degeneration  of 
the  neuro-epithelium,  which  is  hereditary,  it  should  be  classed  as  an 
.abiotrophy. 


SYMMETRIC  FAMILIAL  PIGMENTARY  MACULAR  DEGENERATION. 

PRIMARY  DEGENERATION,  OR  ABIOTROPHY,  OF  THE  CONES  AT 

THE  MACULA 

De  Wecker,  in  1868,  divided  cases  of  retinitis  pigmentosa  in  two 
groups:  One  which  occurs  in  children,  with  comparatively  rapid  loss 
of  central  vision,  and  which  is  frequently  associated  with  mental  de- 
fects; the  other,  comprising  the  ordinary  cases,  beginning  with 
night-blindness  early  in  life,  progressing  very  slowly,  the  central 
vision  remaining  unaffected  until  late  in  the  disease,  and  in  connection 
with  which  mental  failure  is  but  rarely  met. 

Nettleship17  also  described  atypical  cases  of  retinitis  pigmentosa 
with  central  changes.  He  pointed  out  that  the  pigmentation  in 
them  was  in  the  form  of  scattered  dots,  instead  of  bone-corpuscle- 
shaped  patches;  and  that  the  patients,  instead  of  being  night-blind, 
preferred  a  dull  light. 

Several  cases  have  been  recorded  of  recent  years  of  primary  macular 
pigmentary  degeneration,  occurring  in  several  members  of  the  same 
family,  often  in  association  with  cerebral  degeneration,  but  sometimes 
without.  These  cases  have  been  described  under  the  following  head- 
ings: " Family  Cerebral  Degeneration  with  Macular  Changes" 
(Batten  and  Mayou);  " Maculocerebral  Degeneration  (Familial)" 
(Oatman);  "Progressive  Familial  Macular  Degeneration"  (Darier). 
None  of  these  titles  is  satisfactory.  From  the  two  first  it  would  be 
inferred  that  the  cerebral  changes  were  an  essential  part  of  the  disease, 
and  from  the  third  that  the  disease  tended  to  progress  to  complete 
loss  of  sight.  I  and  others  have  recorded  cases  which  have  manifested 


120  E.  TREACHER  COLLINS 

no  mental  symptoms,  some  of  them  having  been  kept  under  observation 
for  several  years.  The  disease,  when  it  commences  at  the  macula,  gener- 
ally remains  confined  to  that  region  and  does  not  progress  beyond  it. 

The  reason  that  the  pigment  patches  in  retinitis  pigmentosa  assume 
a  bone-corpuscle  shape  is  due  to  the  pigment  epithelial  cells  making 
their  way  into  the  lymphatic  sheaths  around  the  retinal  blood-vessels ; 
as  there  are  no  blood-vessels  in  the  retina  at  the  macula,  when  the 
pigment  epithelial  cells  migrate  into  the  retinal  tissue  in  that  region 
they  do  not  form  branching  patches,  but  rounded  dots. 

The  histologic  changes  in  an  eye  of  a  typical  case  with  symmetric 
pigmentary  changes  at  the  macula  in  each  eye  have  been  investigated 
by  Mayou.23  He  found  that  the  sclera  and  choroid  were  practically 
normal,  the  pathologic  changes  being  confined  to  the  retina.  Briefly, 
they  consisted  of  a  complete  disappearance  of  the  cones  and  the  neural 
elements  of  the  retina,  together  with  some  increase  of  the  supporting 
neuroglia  and  migration  of  pigment  epithelial  cells,  to  a  slight  extent, 
into  the  outermost  layers  of  the  retina.  Mayou.  in  commenting  on 
this  case,  inclined  to  the  view  that  the  primary  change  was  in  the 
ganglion-cells  of  the  retina,  and  that  the  disappearance  of  the  cones 
and  the  migration  of  pigment  were  secondary.  Coats,24  however,  in 
commenting  on  this  case  in  a  later  article,  wrote  very  shrewdly  as 
follows:  "There  is,  I  believe,  no  known  instance  of  a  disease  which 
first  attacks  the  inner  retinal  neural  elements  and  then  the  outer, 
although  instances  of  the  opposite  sequence  of  events  might  be  cited ; 
nor  does  destruction  of  the  inner  layers  from  whatever  cause  produce 
any  consecutive  secondary  change  in  the  outer,  however  long  the  dur- 
ation of  obstruction  of  the  central  artery  or  primary  optic  atrophy,  in 
which  the  rods  and  cones  and  outer  nuclear  layer  remain  permanently 
intact. " 

When  the  general  nervous  system  is  affected  in  connection  with 
this  pigmentary  degeneration,  there  is  a  progressive  dementia  and 
paralysis  ending  in  death.  After  some  years  of  normal  development 
the  mental  degeneration  sets  in,  accompanied  sometimes  by  epileptic 
fits;  before  death  the  patients  become  noisy,  dirty  in  habits,  and  de- 
velop a  spastic  condition  of  the  limbs.  In  two  cases  examined  post- 
mortem by  Dr.  F.  E.  Batten  M  diffuse  degenerative  changes  were  visi- 
ble microscopically,  affecting  the  ganglion-cells  in  the  cerebrum, 
cerebellum,  and  spinal  cord.  These  changes,  he  says,  were  similar  to 
those  found  in  amaurotic  family  idiocy. 

From  the  account  already  given  of  retinitis  pigmentosa,  and  from 


Hereditary  Ocular  Degenerations 


121 


that  which  follows  of  amaurotic  family  idiocy,  it  will  be  seen  that  this 
primary  pigmentary  macular  degeneration  presents  some  resem- 
blances to  each  of  those  affections,  and  also  some  striking  differences. 
These  resemblances  and  differences  are  set  out  in  tabular  form  as 
follows : 


Retinitis 
Pigmentosa 

Macular  Pigmentary 
Degeneration 

Amaurotic  Family 
Idiocy 

Age  and  prog- 

ress     

Commences  early  in 

May  commence    at 

Onset  at  age  of  three 

life  and  progresses 

age  of  six  or  not 

to       six       months; 

slowly. 

until  the  second  de- 

rapid   failure    of 

cade;  rapid  failure 

sight;  death  in  two 

of  sight  and  then 

years. 

stationary. 

Heredity  

More  than  one  gen- 

Familial,   no   racial 

Familial  ;    only   met 

eration  affected;  no 

proclivity. 

with  in  the  Jewish 

racial  proclivity. 

race. 

Visual  defect 

Night-blindness  fol- 

Central scotoma  ;  no 

Central  loss  of  sight 

lowed   by   annular 

contraction  of  field; 

early,      progressing 

scotoma;      central 

no  night-blindness. 

to   complete  blind- 

vision last  affected. 

ness. 

Condition   of 

retina  

Primary  affection  of 

Primary  affection  of 

Primary  affection  of 

bacillary  layer   at 

bacillary    layer    at 

ganglion-cells,  caus- 

equator;  later  for- 

macula;   later  for- 

ing   white    opacity 

mation  of  branch- 

mation of  dots  of 

around  macula. 

ing  patches  of  pig- 

pigmentation. 

mentation. 

General    ner- 

vous system 

Sometimes     mental 

Sometimes    demen- 

Always      dementia. 

weakness,        cause 

tia;     ganglion-cells 

All     ganglion-nerve 

unknown. 

affected  as  in  am- 

cells    in    body    in- 

aur ot  i  c  family 

volved. 

idiocy. 

The  eye  symptoms  in  all  three  affections  are  due  to  some  innate 
tendency  to  degeneration  in  the  cells  of  the  retina.  The  difference 
which  they  present  in  the  three  affections  is  due  to  the  difference  in  the 
cells  involved.  Any  one  of  them  may  be  accompanied  by  a  similar  in- 
nate tendency  to  degeneration  in  ganglion-cells  of  the  central  nervous 
system.  All  three  affections  may,  I  suggest,  be  conveniently  classified 
as  varieties  of  abiotrophy. 


FAMILY  AMAUROTIC  IDIOCY  (TAY-SACHS'  DISEASE).    ABIOTROPHY  OF 

THE  GANGLION-CELLS  OF  THE  RETINA 

A  considerable  amount  of  evidence  has  accumulated  of  recent  years 
as  to  the  pathologic  changes  met  with  in  the  nervous  system  and  retina 
in  cases  of  family  amaurotic  idiocy. 


122  E.  TREACHER  COLLINS 

All  writers  on  the  subject  are  agreed  that  there  is  no  evidence  of  in- 
flammatory changes  in  the  affected  parts,  and  that  the  disease  is  due 
to  a  primary  change  in  the  cells  themselves.  Gordon  Holmes  showed 
that  this  change  was  not  due  to  an  arrest  of  their  development  or  to 
any  bacterial  toxin.  The  essential  histologic  features  of  the  disease 
are :  a  progressive  loss  of  the  Nissl  substance  in  all  the  neurons  of  the 
body,  and  the  increase  of  the  neuroglia  fibril  substance  to  an  abnormal 
degree.  A  chemical  examination  of  the  brain  in  two  cases  by  Sidney 
A.  Mann  showed:  (1)  A  decrease  of  nucleoproteid,  which  may  be 
associated  with  the  disappearance  of  the  Nissl  substance  in  the  neur- 
ons; and  (2)  The  increase  of  simple  proteid,  which  may  be  correlated 
with  the  increase  of  glial  fibrils.  Both  Gordon  Holmes25  and  Sir 
Frederick  Mott26  attribute  the  cell  changes  to  some  faulty  biochemical 
process  in  the  protoplasm  of  the  cells.  The  latter  sums  up  his  con- 
clusions on  the  matter  as  follows : 

"  The  fact  that  it  affects  the  children  of  Jewish  parents  suggests  that 
it  owes  its  origin  to  some  racial  inborn  tendency  to  neuronic  decay, 
probably  associated  with  some  exciting  or  predisposing  factor  con- 
nected with  an  altered  condition  in  the  chemical  composition  of  the 
blood,  whereby  the  normal  biochemical  interaction  of  the  nucleus  on  the 
cytoplasm  and  the  environmental  lymph  on  the  neuron  is  interfered 
with.  'A  cell  nourishes  itself  and  is  not  nourished'  is  as  true  for  the 
highly  complex  and  specially  differentiated  nerve  cell,  with  its  multiple 
processes  and  their  arborizations,  as  for  a  simple  unicellular  organism. 
The  nucleus  is  the  trophic  center  of  the  nerve-cell,  and  possesses  the 
specific  inherent  energy  upon  which  the  cell  depends  for  its  vital 
activities  and  durability.  We  may,  therefore,  suppose  that  this  ex- 
traordinary neuronic  regressive  metamorphosis  is  brought  about  by  a 
conspiracy  of  morbid  factors,  viz.,  an  inherent  racial  lack  of  specific 
neuronic  energy  and  some  general  alteration  in  the  chemical  composi- 
tion of  the  blood,  either  by  the  existence  in  it  of  a  neurotoxin  or  the 
failure  of  some  chemical  substance  in  sufficient  quantitjr  for  the  build- 
ing up  of  the  nucleoproteid  substance  of  the  nervous  system." 

The  cause  of  the  opacity  of  the  retina,  seen  around  the  macula,  in 
these  cases  was  for  some  time  a  matter  of  uncertainty,  due  to  the 
difficulty  in  obtaining  specimens  free  from  postmortem  changes  and 
suitably  fixed.  Within  two  hours  of  death  changes  in  the  retina  set  in, 
causing  it  to  swell,  become  rucked,  and  then  present  microscopically 
the  appearances  of  edema  or  of  a  hole  at  the  fovea.  This  edematous 
change  was  the  most  striking  feature  which  I  discovered  in  the  first 


Hereditary  Ocular  Degenerations  123 

specimen  of  the  sort  which  was  examined  microscopically,  and  I  at- 
tributed the  opacity  seen  ophthalmoscopically  to  edema.  Since  then 
fresher  material  has  been  obtained,  fixed  in  Zenker  's  solution,  sections 
of  which  have  shown  a  complete  absence  of  any  edema,  but  well-marked 
changes  in  the  ganglion-cell  and  nerve-fiber  layers.  There  can  now  be 
no  doubt  that  it  is  the  altered  condition  of  the  ganglion-cells  which 
give  rise  to  the  opacity.  Where  they  are  most  numerous  around  the 
macula,  there  the  opacity  is  densest.  The  changes  in  the  ganglion- 
cells  of  the  retina  resemble  those  found  in  the  ganglion-cells  of  the 
nervous  system  elsewhere.  At  first  they  appear  somewhat  swollen, 
then  there  is  a  gradual  progressive  loss  of  Nissl  substance,  followed 
by  the  formation  of  vacuoles  in  the  cytoplasm,  and  finally  shrinkage  or 
disappearance  of  the  cell.  As  Coats  pointed  out,  the  long  continuance 
of  the  opacity  of  the  retina  around  the  macula  may  be  correlated  with 
the  long  time  the  degenerative  change  in  the  cells  is  going  on  before 
they  finally  disappear.  Very  different  is  this  to  the  short  duration 
of  the  opacity  of  the  retina,  similarly  situated,  in  cases  of  embolism 
of  the  central  artery  of  the  retina,  which  is  due  to  a  coagulative 
necrosis  of  the  ganglion-cells,  after  which  they  become  rapidly  ab- 
sorbed and  disappear. 

Transverse  sections  of  the  optic  nerve  in  advanced  cases  of  amau- 
rotic  idiocy  show  that  the  nerve-fibers  have  nearly  all  disappeared, 
the  few  remaining  fibers  being  fine  ones  and  irregular  with  varicosities. 

There  is  some  difference  of  opinion  as  to  the  appropriateness  of  the 
use  of  the  term  abiotrophy  as  descriptive  of  the  changes  met  with  in 
family  amblyopic  idiocy.  Sachs27  says  he  gladly  accepts  it  as  indicat- 
ing the  nature  of  the  changes  met  with.  Gordon  Holmes,25  on  the 
other  hand,  writes:  "The  cell  changes  have  not  the  characters  of  a 
simple  atrophy;  in  fact,  they  seem  to  be  due  to  an  excessive  growth 
of  the  protoplasm  which  later  undergoes  degenerative  changes.  This 
fact  is  not  in  favor  of  Sachs'  hypothesis  that  the  pathology  of  the  dis- 
ease can  be  described  by  the  term  abiotrophy  (a  term  suggested  by 
Gowers  to  represent  an  inherent  defective  vitality  of  the  cell),  or  of 
Schaff er  's  suggestion  that  it  may  be  explained  by  Edinger  's  '  Ersatz- 
theorie, '  which  assumes  that  the  elements  which  are  inherently  feeble 
undergo  degeneration  when  exposed  to  the  strain  of  life  to  which  they 
are  not  normally  resistant." 

There  can  be  no  doubt  that  the  change  in  the  ganglion-cell  is  a  form 
of  hereditary  ocular  degeneration.  The  degeneration,  as  already 
mentioned,  is  of  a  different  character  to,  and  of  slower  progress  than, 


124  E.  TREACHER  COLLINS 

that  which  takes  place  when  these  cells  are  deprived  suddenly  of  their 
nutrient  supply  by  occlusion  of  the  central  retinal  artery.  If,  as  Mott 
suggests,  the  degeneration  is  in  part  due  to  the  failure  in  the  inherent 
specific  trophic  influence  of  the  nucleus  of  a  nerve-cell,  upon  which  the 
vitality  of  the  whole  neuron  depends,  then  the  term  abiotrophy  is  as 
appropriate  as  any  that  has  been  invented  under  which  to  classify  the 
affection.  Even  though  the  first  stage  in  the  trophic  disturbance 
presents  the  appearance  of  hypertrophy,  the  final  stage  in  the  process 
is  invariably  the  premature  death  and  atrophy  of  the  affected  cell. 


HEREDITARY  OPTIC  ATROPHY.     " OPTIC  ABIOTROPHY" 

The  occurrence  of  what  was  termed  "amaurosis"  in  several  mem- 
bers of  the  same  family  was  first  described  by  Beer  in  1817.  Leber28 
published  his  classic  paper  on  hereditary  optic  atrophy  in  1871.  Many 
cases  of  the  same  description  have  since  been  recorded,  and  much  has 
been  written  on  the  subject,  but,  so  far  as  I  am  aware,  no  pathologic 
examination  has  been  made  of  these  cases  and  we  are,  therefore,  still 
ignorant  as  to  the  real  nature  of  the  disease. 

Gowers,29  in  1904,  described  the  affection  under  the  heading  of 
"Optic  Abiotrophy,"  and  spoke  of  it  as  follows: 

"Since  some  cases  were  discerned  by  Leber,  much  attention  has 
been  given  to  the  form  of  optic  atrophy  which  occurs  in  families, 
sometimes  through  more  than  one  generation,  soon  after  adult  life  is 
attained.  Similar  cases  occur  in  sporadic  form,  isolated,  as  do  other 
family  maladies.  The  facts  suggest  that  the  inherent  vital  energy  of 
these  structures  is  inadequate  to  maintain  their  nutrition  much  be- 
yond full  development,  so  that  they  gradually  fail  and  degenerate. 
They  fail  from  imperfect  life,  from  abiosis,  in  what  may  be  designated 
abiotic  atrophy,  or  abiotrophy.  The  same  atrophic  failure  is  met 
with  in  other  parts  of  the  nervous  system,  as  in  Friedreich's  disease, 
and  conspicuously  in  the  muscles  in  the  varieties  of  muscular  dys- 
trophy. 

"  It  is  noteworthy  that  even  vital  failure  is  often  associated  with  ex- 
traneous influences.  Even  in  the  cases  in  which  the  family  disposition 
is  most  marked,  the  onset  is  often  the  immediate  sequel  of  some  ad- 
ventitious cause.  It  follows  some  acute  specific  disease,  or,  in  males, 
excessive  smoking,  and  this  in  cases  in  which  the  family  tendency  is  so 
marked  as  to  compel  us  to  regard  the  excitant  as  merely  such,  an 
opinion  which  is  confirmed  by  the  slow  progress  of  the  atrophy  after 
the  cessation  of  the  immediate  influence.  In  such  cases  the  interstitial 


Hereditary  Ocular  Degenerations  125 

tissue  undergoes  overgrowth,  in  consequence  of  the  solidarity  of  the 
vital  tendency  of  the  two  structures,  both  of  which  arise  from  the  same 
embryonal  elements.  When  the  vitality  of  the  higher,  neural  elements 
fails,  that  of  the  residual,  neuroglial  elements  becomes  exuberant, 
and  may  even  display  an  energy  which  carries  it  beyond  the  strict 
limits  of  the  neural  failure.  Thus  we  are  able  to  understand  some 
features  of  this  form  which  at  first  seem  mysterious.  It  must  be  re- 
membered, also,  that  the  defect  in  vital  endurance  varies  in  degree 
and  in  extent  even  within  the  range  of  the  tissue  which  presents  it. 
How  grave  it  may  be  we  cannot  know  until  it  is  revealed  by  time,  but 
the  influence  of  a  powerful  excitant  may  at  least  afford  ground  for 
hope,  and  indicate  room  for  treatment.  It  should  be  remembered  also 
that,  in  such  maladies,  therapeutic  measures,  when  most  effective, 
may  only  prevent  further  failure. " 

In  1916  J.  H.  Fisher,30  without  taking  into  consideration  Gowers' 
views  on  the  nature  of  this  affection,  put  forward  a  new  hypothesis  as 
to  its  causation;  he  wrote  as  follows: 

"It  has  occurred  to  me  that  if  a  disturbance  of  the  pituitary  body 
of  temporary  duration  and  moderate  degree  can  be  imagined,  such  a 
lesion  might  be  adequate  to  explain  the  phenomena  of  Leber  's  heredi- 
tary optic  atrophy,  in  which  case  the  inherited  tendency  would  not 
lie  in  a  special  vulnerability  of  the  macular  fibers  of  the  optic  nerves, 
but  in  a  liability  of  the  pituitary  body  to  such  limited  disorder  as  I 
suggest.  A  priori  it  is  to  me  much  easier  to  imagine  an  inherited 
tendency  to  disorder  of  the  hypophysis  than  a  family  tendency  on  the 
part  of  the  papillomacular  fibers  of  the  optic  nerve  to  degenerative 
or  inflammatory  attacks." 

The  points  upon  which  Fisher  based  this  hypothesis  are: 

I.  That  cases  of  bilateral  temporal  hemianopsia,  due  to  pressure  on 
the  chiasma,  have  been  known  to  develop,  in  the  first  instance,  a 
central  scotoma. 

II.  That  individuals  who  develop  hereditary  optic  atrophy  are  often 
of  what  Leber  described  as  the  neuropathic  type.     They  are  subject 
to  frontal  headache,  vertigo,  and  epileptiform  attacks;    they  also  ex- 
perience subjective  phenomena  of  light  and  color.     Fisher  suggests 
that  these  symptoms  may  be  taken  as  suggestive  of  pathologic  dis- 
turbance or  excessive  physiologic  activity  on  the  part  of  the  pituitary 
gland. 

III.  That  the  affection  often  coincides  in  its  onset  with  puberty,  or 
in  women,  the  climacteric  period,  at  which  times,  Fisher  suggests, 


126  E.  TREACHER  COLLINS 

variations  in  the  size  of  the  pituitary  body  are  most  likely  to  be  met 
with. 

IV.  That  glycosuria  is  sometimes  associated  with  a  loss  of  central 
vision,  similar  in  some  respects  to  that  met  with  in  Leber's  disease, 
and  that  disorders  of  the  posterior  lobe  and  pars  intermedia  of  the 
pituitary  body  is  frequently  accompanied  by  glycosuria. 

V.  That  lesions  of  the  optic  chiasma  due  to  pituitary  body  enlarge- 
ment or  growth  may,  in  the  early  stages  of  the  affection,  give  rise  to  a 
very  mild  papillitis,  and  that  this  symptom  has  also  been  noticed  in 
the  early  stages  of  Leber's  disease.     While  in  the  later  stages  of  both 
affections  signs  of  optic  atrophy  present  themselves  in  the  optic  disc. 

VI.  That  in  some  cases  of  the  disease  which  have  been  examined 
with  the  x-rays  an  abnormal  appearance  has  been  observed  in  the 
vicinity  of  the  sella  turcica. 

Difficulties  present  themselves  in  the  acceptance  of  either  Gowers' 
or  Fisher's  theory  as  to  the  pathology  of  hereditary  optic  atrophy. 

If  we  regard  the  disease  as  a  form  of  abiotrophy,  it  would  be  neces- 
sary to  determine  the  structure  in  which  the  degeneration  commences. 
As  the  failure  of  sight  in  the  most  typical  cases  is  restricted  to  the 
central  region,  it  would  be  most  natural  to  locate  it  in  the  ganglion- 
cells  from  which  the  fibers  start,  which  constitute  the  papillomacular 
bundle.  In  diseases  in  which  the  ganglion-cells  of  the  retina  are 
known  to  be  affected  with  degenerative  changes,  such  as  embolism  of 
the  central  artery  of  the  retina,  quinin  amblyopia,  and  amaurotic 
family  idiocy,  for  a  time,  varying  induration  in  the  different  affections, 
an  opacity  of  the  retina  is  seen  ophthalmoscopically.  No  such  opacity 
has  been  observed  in  Leber's  disease,  though  there  is  often,  at  first, 
a  temporary  appearance  suggesting  edema  about  the  optic  disc.  That 
temporary  opacity  of  the  retina  is  not  an  essential  preliminary  phenom- 
enon in  the  onset  of  primary  atrophy  of  the  optic  nerve  we  know,  from 
its  absence  in  connection  with  primary  atrophy  of  tabes.  In  this 
latter  affection  we  have  no  certain  knowledge  as  to  which  part  of  the 
affected  neuron  is  primarily  involved. 

One  of  the  most  constant  characteristics  of  diseases  attributable  to 
abiotrophy  is  their  incurability;  there  is  a  degeneration  due  to  loss  of 
vitality,  and  once  lost,  it  is  not  restored.  There  are  cases  of  hereditary 
optic  atrophy  on  record  in  which  complete  or  partial  recovery  has 
taken  place;  thus  Nettleship  writes: 

"I  find  records  of  at  least  25  affected  persons  (22  males,  3  females) 


Hereditary  Ocular  Degenerations  127 

in  16  genealogies  who  recovered  either  perfect  or  quite  useful  central 
vision;  minor  degrees  of  improvement  are  probably  rather  common. " 

"In  the  same  genealogy,  and  even  in  the  same  sibship,  some  may 
recover  and  others  not. "  "A  very  important  feature  in  these  cases  is 
the  length  of  time  that  may  elapse  before  notable  improvement  of 
sight  begins, — often  twelve  or  eighteen  months,  and  in  one  case,  if  we 
can  believe  the  history,  as  much  as  three  years." 

Gowers  would  probably  attribute  recovery,  or  partial  recovery,  in 
such  cases  to  variations  of  intensity  in  "the  adventitious  cause," 
which,  he  pointed  out,  in  the  quotation  given  above,  is  necessary,  in 
addition  to  the  family  disposition,  for  the  production  of  this  disease. 

The  most  tangible  factor  for  consideration  in  connection  with 
Fisher's  hypothesis  is  the  appearances  shown  by  x-ray  examination. 

The  table  on  p.  128  gives  the  result  of  examination  of  the  sella  tur- 
cica  by  x-rays  in  Fisher's,30-31  Pollock's,32  and  Dr.  James  Taylor's33 
cases,  together  with  three  cases  I  have  had  under  my  own  observa- 
tion, one  hereditary  and  two  sporadic. 

The  results  of  x-ray  examinations,  which  are  given  in  the  table, 
seem  to  show  that  there  may  be  some  association  between  the  loss  of 
central  vision  met  with  in  Leber  's  disease  and  changes  in  the  vicinity 
of  the  sella  turcica.  Fisher  naturally  regards  this  as  affording  support 
to  his  hypothesis,  that  the  affection  is  due  to  changes  in  the  pituitary 
body.  Indeed,  it  was  with  the  idea  of  testing  his  hypothesis  that  he 
first  undertook  these  x-ray  examinations. 

So  far  no  well-recognized  case  of  hereditary  optic  atrophy  has  been 
known  to  develop  bitemporal  hemianopsia,  and  we  do  not  know  of  any 
hereditary  form  of  pituitary  disease,  whereas  we  are  well  acquainted 
with  bilateral  degenerative  conditions  affecting  the  nervous  system, 
such  as  Friedreich's  disease,  due  to  atrophy  of  the  motor  neurons,  a 
typical  abiotrophy.  It  would  seem  well,  therefore,  to  consider  how 
Gowers'  theory  of  abiotrophy,  applied  to  Leber 's  optic  atrophy, 
might  account  for  changes  in  the  vicinity  of  the  sella  turcica,  such  as 
are  revealed  by  x-ray  examination.  Gowers,  as  quoted  above,  speaks 
of  overgrowth  of  neuroglia  in  the  optic  nerve  in  Leber 's  disease;  this  is 
not  the  result  of  direct  observation,  as  the  optic  nerves  in  this  affection 
have  not  yet  been  examined  pathologically.  He  must  have  inferred 
the  presence  of  such  overgrowth  from  the  presence  of  similar  over- 
growth in  the  nervous  system  in  other  forms  of  abiotrophy.  There  is, 
however,  ophthalmoscopic  evidence  which  affords  support  to  the  view 
that,  associated  with  atrophy  of  the  nerve  elements  in  this  disease, 


128 


E.  TREACHER  COLLINS 


Recorder 

Sex 

Age 

Duration 
of 
Affection 

Results  of  x-ray  Examination 

Fisher  

Male 

14 

2  vrs. 

Sella  turcica  shows  no  departure 

Fisher   

Female 

ll\4 

6  mos. 

from  normal. 
Sella  turcica  not  enlarged,  out- 

Fisher ........ 

Male 

22 

3  mos. 

line  not  distorted,  but  the  de- 
pression filled  in  with  something 
which  gives  a  cellular  or  honey- 
comb-like shadow. 
Sella  turcica  outline  slightly  in- 

Fisher 

Female 

\zy2 

5  mos. 

distinct  posteriorly,   but  it  is 
not  enlarged  or  distorted. 
Pituitary  fossa  showed  nothing 

Sporadic  case 
Fisher    

Female 

49 

1  wk. 

abnormal.    Seven  months  later 
fossa  was  found  to  be  normal  in 
size  and  outline,  but  there  was 
a  domed  shadow  which  formed 
a  roof  over  the  sella  turcica. 
Four   months   later   still   sella 
turcica    again   showed    domed 
shadow  roofing  completely  the 
fossa. 
Doubtful    enlargement    of    the 

Sporadic  case 
Pollock  

Female 

11 

6  mos. 

pituitary  fossa  and  some  want 
of  distinction  of  the  posterior 
clinoid    processes.      A    second 
examination,  made  nine  months 
later,  showed  more  marked  ap- 
proximation of  the  anterior  and 
posterior  clinoid  processes. 
Situated  a  little  below  the  center 

Pollock    

Male 

8 

1  mo. 

of  the  sella  turcica,  a  shadow 
like    a   small    bean,    with    the 
concavity  downward. 
Same  appearances  as  in  the  case 

James  Taylor  .  . 

James  Taylor  .  . 

Treacher    Col- 
lins   

Male 
Male 
Male 

52 
60 
42 

A  few 
months 

10  yrs. 
6  mos. 

last  recorded,  that  of  his  sister. 
Sella  turcica  long  and  shallow; 
clinoid  processes  certainly  not 
normal. 
Sella  turcica  shallow,  and  clinoid 
processes  reduced  in  size. 

Sella    turcica    distinctly    large. 

Treacher     Col- 
lins        

Male 

24 

6  wks. 

and   the   opening   into   it   ap- 
parently wider  than  usual. 

The  floor  of  the  pituitary  fossa  is 

Sporadic  case 

Treacher     Col- 
lins   

Female 

33 

14  mos. 

very  shallow  and  flattened,  also 
irregular.    The  anterior  clinoid 
processes     are     unduly     pro- 
nounced,    and    the    posterior 
processes  barely  evident  at  all. 

No  abnormal  changes  seen  in  the 

Sporadic  case 

region  of  the  sella  turcia. 

Hereditary  Ocular  Degenerations  129 

there  takes  place  an  excessive  formation  of  neuroglia.  After  the  dis- 
ease has  been  in  existence  for  some  time  pallor  of  the  outer  half  of  the 
disc  commences,  and  spreads  over  its  whole  surface.  Leber  himself 
described  this  pallor  as  due  to  increase  of  the  connective-tissue  ele- 
ments of  the  nerve.  If,  then,  there  is  an  overgrowth  of  neuroglia  at 
the  head  of  the  nerve  in  this  disease,  we  may  be  sure  that  there  is  also 
a  similar  overgrowth  along  the  track  of  the  papillomacular  fibers  else- 
where. The  greatest  thickening  of  this  neuroglia  would  be  expected 
to  occur  where  the  affected  fibers  in  the  two  nerves  came  together,  at 
the  chiasma.  A  thickening  of  the  chiasma,  due  to  overgrowth  of 
neuroglia,  might  press  down  the  pituitary  body,  just  as  an  enlarge- 
ment of  the  latter  may  press  up  the  chiasma;  or  might  also,  in  a 
skiagram  of  the  sella  turcica,  give  rise  to  the  appearance  of  a  roof-like 
covering  to  it,  or  of  a  bean-shaped  body  overlying  it. 

All  these  speculations  as  to  the  real  nature  of  hereditary  optic 
atrophy  might  be  cleared  up  by  the  pathologic  examination  of  a  typi- 
cal case.  The  best  way  to  make  known  the  urgent  need  of  pathologic 
evidence  of  this  description  is,  I  think,  to  proclaim  it  to  the  members 
of  a  large  congress  such  as  this. 


DOYNE 's  "FAMILY  CHOROIDITIS, "  OR  ABIOTROPHY  OF  THE  RETINAL 
PIGMENT  EPITHELIUM 

R.  W.  Doyne34  described  a  form  of  family  choroiditis  in  1899  and 
1910.  In  his  last  communication  concerning  it  he  summarizes  the 
condition  as  follows:  "It  first  appears  in  early  adult  life,  but  much 
more  commonly  later.  It  may  either  affect  the  disc  neighborhood  or 
the  macula  neighborhood,  or  the  disc  macula  area.  It  consists  of 
circular  patches  of  exudation ;  these  increase  during  middle  age,  and 
at  least  set  up  some  irritation  and  pigmentary  disturbance,  for,  though 
pigment  is  not  always  present,  in  some  cases  there  is  a  good  deal  to  be 
seen.  During  this  stage  the  sight,  though  affected,  is  not  grossly  in- 
terfered with.  In  old  age  the  condition  passes  into  atrophy,  with  a 
corresponding  degree  of  failure  of  sight. " 

He  had  met  with  the  condition  in  two  families,  affecting  several 
members  of  each,  in  the  same  and  in  different  generations.  A  similar 
condition  in  the  members  of  another  family,  a  mother  and  two  daugh- 
ters, was  described  by  Major  Mould35  in  1910. 

At  the  conclusion  of  his  communication  in  1910  Doyne  wrote: 
•"I  am  keeping  my  attention  carefully  on  some  of  the  older  cases,  and 
9 


130  E.  TREACHER  COLLINS 

I  hope,  if  I  live  long  enough,  I  may  be  able  to  bring  before  the  Society 
some  microscopic  sections."  Doyne's  health  failed  him  in  1913,  so 
that  he  had  to  retire  from  practice,  but  that  year  one  of  the  elderly 
patients  with  this  affection,  whom  he  had  been  keeping  under  obser- 
vation, died,  and  he  obtained  the  backs  of  his  eyes,  which  he  handed 
over  to  me  for  pathologic  examination.  In  making  the  examination 
I  had  no  preconceived  notion  or  theory  as  to  what  the  condition  was 
and  wrote  the  following  description  of  the  histologic  appearances  which 
the  specimen  presented.  Mr.  Doyne  showed  the  specimen  at  the  Ox- 
ford Ophthalmological  Congress  in  1913,  and  the  description  of  it  was 
published  in  that  year.36 

"In  sections  through  the  posterior  part  of  the  eyeball  in  the  region 
of  the  macula  and  optic  disc  are  seen  the  following  changes.  Situated 
between  the  retina  and  choroid  is  a  new  formation  of  a  hyaline  sub- 
stance. It  commences  on  each  side  of  the  optic  disc  close  to  its  margin, 
and  extends  inward  from  it  about  a  distance  of  two  discs '  breadth,  and 
outward  a  distance  of  six  discs'  breadth.  Its  external  surface  has  a 
regular  contour  following  natural  curve  of  the  choroid.  Its  inner,  or 
retinal,  surface  presents  several  rounded  nodular  elevations  with  de- 
pressions between  them.  The  thickness  of  the  hyaline  substance 
varies,  therefore,  considerably  in  different  parts.  It  shows  in  places 
very  definite  lamination,  and  for  the  most  part  is  entirely  free  from 
cells,  although  here  and  there  a  cell  with  a  flattened  nucleus  is  seen 
embedded  in  it. 

"The  choroid  external  to  the  hyaline  tissue  shows  marked  thinning, 
and  in  places  complete  absence,  of  its  internal  capillary  layer.  The 
vessels  of  the  outer  layer  appear,  however,  abnormally  large,  but  their 
walls  are  not  thickened.  In  the  choroid,  on  the  outer  side  of  the 
optic  disc,  there  is  a  small  area  of  round-cell  exudation,  but  apart 
from  this  there  are  no  signs  of  inflammatory  disturbance.  Where  the 
hyaline  substance  is  present,  the  elastic  lamina  of  the  choroid  or  mem- 
brane of  Bruch  cannot  be  satisfactorily  differentiated.  At  the  periph- 
ery of  the  hyaline  substance,  on  each  side,  the  pigment  epithelium 
can  be  seen  extending  for  a  short  distance  over  its  inner  surface  as  a 
single  layer  of  cells.  Large  parts  of  the  inner  surface  of  the  hyaline 
substance  are,  however,  devoid  of  any  lining  of  pigment  epithelium, 
while  here  and  there  irregular  collections  of  pigment  epithelial  cells 
are  met  with.  The  outer  surface  of  the  retina  has  become  much 
disorganized  by  the  formation  of  the  hyaline  tissue.  The  rod-and- 
cone  layer  has  become  entirely  destroyed  where  it  is  situated,  also  to 


Hereditary  Ocular  Degenerations  131 

a  very  large  extent  the  outer  nuclear  layer.  In  some  localities  the 
granular  layers  are  thickened,  the  fibers  crossing  them  being  stretched 
out  with  spaces  between  them.  The  inner  layers  of  the  retina  show 
but  little  change." 

To  this  description  of  the  appearances  of  the  sections,  I,  in  1913, 
added  the  following  remarks : 

"The  hyaline  substance  in  these  sections  presents  the  same  histo- 
logic  appearances  and  staining  reactions  as  the  nodules  of  hyaline 
commonly  met  with  in  a  similar  situation  in  many  degenerative  condi- 
tions of  the  choroid.  Such  nodules  are  often  termed  'Drusen. '  The 
hyaline  continuous  substance  in  this  specimen  is  peculiar  in  forming 
such  a  long  layer.  In  other  conditions  it  is  usually  in  the  form  of 
isolated  nodules.  The  ophthalmoscopic  changes,  known  as  'Tay's 
choroiditis, '  are  generally  regarded  as  being  due  to  such  nodules. 
Many  different  views  have  been  put  forward  to  account  for  the  forma- 
tion of  these  hyaline  nodules.  They  have  the  same  characteristics  as 
the  elastic  lamina  of  the  choroid,  and  it  seems  probable  that  they  are, 
like  it,  the  product  of  the  pigment  epithelial  cells.  Some  of  the  hya- 
line tissue  in  this  specimen  looks  very  like  a  number  of  superimposed 
layers  of  the  elastic  lamina.  Further,  it  seems  likely  that  the  primary 
change  was  in  the  pigment  epithelium,  and  that  the  changes  in  the 
choroid  and  retina  around  are  secondary  to  the  pressure  caused  by  the 
formation  of  the  hyaline  substance." 

From  the  above  description  of  pathologic  appearances  and  remarks 
it  will  be  seen  that,  in  this  family  affection  first  described  by  Doyne, 
we  have  to  do  with  a  primary  degeneration  of  the  cells  derived  from 
the  outer  layer  of  the  secondary  optic  vesicle,  and  not  with  an  inflam- 
matory affection  of  the  choroid.  The  white  appearance  seen  in  the 
fundus  ophthalmoscopically  is  not  due  to  an  inflammatory  exudation, 
but  to  the  formation  of  hyaline  substance  by  the  cells  involved,  which 
is,  on  their  part,  a  degenerative  process.  A  degeneration  of  this 
nature  handed  down  from  one  generation  to  another,  and  affecting 
several  members  of  the  same  family,  may,  I  suggest,  be  aptly  included 
in  the  class  of  affections  described  by  Gowers  as  "abiotrophies." 

The  affection  is,  I  think,  one  more  commonly  met  with  than  the 
scant  attention  it  so  far  has  received  in  ophthalmic  literature  might 
lead  one  to  expect.  The  slow  progress  of  the  affection,  and  the  ab- 
sence of  symptoms  in  its  early  stages,  render  its  family  nature  likely  to 
be  overlooked.  As  pointed  out  by  Gowers,  though  abiotrophies  are 
usually  hereditary  conditions,  sporadic  cases  of  the  same  nature  some- 


132  E.  TREACHER  COLLINS 

times  occur,  so  it  is  in  this  hyaline  degeneration  of  the  pigment  epithe- 
lium of  the  retina.  This  year  I  have  seen  two  cases  in  which  the 
condition  was  well  marked,  though  no  history  of  failure  of  sight  in  other 
members  of  their  families  could  be  obtained.  From  what  Doyne  has 
said  it  is  evident  that  the  absence  of  a  history  of  heredity  is  not  suffi- 
cient evidence  to  exclude  the  presence  of  the  disease,  as  it  may  be 
present  in  other  members  of  the  family  though  unsuspected  for  many 
years. 


HEREDITARY  DEGENERATION  OF  THE  CORNEA.    ABIOTROPHY  OF  THE 
CORNEAL  NERVES 

A  bilateral  affection  of  the  cornea,  starting  usually  about  puberty, 
and  manifesting  itself  by  the  formation  of  opaque  nodules  in  the  super- 
ficial layers,  was  first  described  by  Groenouw 37  in  1898,  under  the  name 
"  knotchenf ormige  Hornhaut-Triibungen. "  His  description  of  the 
appearances  in  his  two  cases  remains  substantially  true  for  the  many 
others  which  have  since  been  recorded.  He  says:  " The  disease  con- 
sists in  the  development  of  numerous  small,  rounded  or  irregular, 
gray,  discrete  opacities  in  the  otherwise  clear  cornea.  The  larger 
opacities  attain  to  a  diameter  of  nearly  a  %  mm.,  and  between  these 
lie  much  smaller,  dust-like  gray  points;  they,  for  the  most  part,  are 
situated  in  the  central  region  of  the  cornea,  and  rather  avoid  the 
marginal  zone.  The  larger  spots  slightly  raise  the  epithelium  and 
thus  give  a  certain  minute  irregularity  to  the  surface.  The  opacities 
appear  by  degrees  without  any  inflammatory  reaction,  and  may  re- 
main for  years  unchanged." 

The  hereditary  nature  of  the  affection  does  not  seem  at  first  to  have 
been  noted.  In  1902  Marcus  Gunn 38  recorded  four  cases  in  a  family 
of  ten.  Spicer,39  in  1904,  described  a  family  in  which  three  generations 
were  affected.  The  following  is  the  pedigree  of  a  family,  some  of  the 
members  of  which  I  have  had  under  my  own  observation,  in  which 
four  generations  were  affected. 

In  none  of  the  cases  recorded  has  there  been  any  evidence  to  show 
that  the  affection  was  of  a  syphilitic  nature.  Several  observers  have 
described  the  histologic  appearances  of  small  pieces  of  the  cornea, 
either  scraped  off  the  surface  or  trephined.  Paderstein  had  the  op- 
portunity of  examining  the  whole  eye  in  a  case,  it  having  been  removed 
after  death  from  a  patient  who  died  from  suppurative  meningitis 
following  an  injury  to  the  head. 


Hereditary  Ocular  Degenerations 

T 


133 


T"          ~T 

>)           ®            ® 

6" 

O 


III 


9 


6 


IV 


6 


The  changes  found  are  situated  in  the  basal  cells  of  the  epithelium, 
between  the  epithelium  and  Bowman's  membrane,  in  Bowman's 
membrane  itself,  and  in  the  superficial  layers  of  the  parenchymatous 
tissue  of  the  cornea.  Paderstein40  said  that,  on  first  looking  at  the 
specimens,  one  gets  the  impression  that  the  disease  affects  primarily 
Bowman's  membrane;  closer  inspection,  however,  shows  that  the 
primary  seat  of  the  disease  is  in  the  basal  epithelium.  He  considers 
that,  through  a  degenerative  process  taking  place  in  the  epithelial  cells, 
the  nuc'eus  is  destroyed  and  the  protoplasm  changed  into  a  hyaline 
substance.  This  hyaline  substance  tends  to  accumulate  on  the  sur- 
face of  Bowman 's  membrane.  Fuchs,41  in  his  most  recent  article  on 
the  subject,  states  that:  "The  main  points  are  that  in  this  affection 
two  primary  changes  are  present,  i.  e.,  the  deposition  of  a  substance 
that  is  often  in  layers  immediately  under  the  epithelium,  and  gives  an 
acidophile  reaction,  and  a  second  basophile,  granular  substance  in  the 
cornea  proper. "  He  is  inclined  to  think  that  the  acidophile  is  a  later 
product  than  the  basophile  substance,  since  the  latter  has  been  found 


134  E.  TREACHER  COLLINS 

in  all  the  reported  cases,  while  the  former  has  not  been  always  present. 
He  describes  as  accessory  changes  the  alteration  in  the  epithelium,  the 
thinning  and  destruction  of  Bowman's  membrane,  and  the  separation, 
swelling,  or  destruction  of  the  corneal  lamellae.  Fuchs  considers  the 
affection  to  be  of  the  nature  of  a  dystrophy,  and  comparable  to  other 
similar  processes  found  in  old  age,  as  the  result  of  disturbance  of  general 
nutrition  or,  as  a  result  of  interference  with  the  internal  secretion  of 
certain  glands,  as  in  myxedema. 

Besides  the  nodular  opacities  above  described,  hereditary  degenera- 
tion of  the  cornea  may  take  on  the  appearance  of  a  trelliswork,  or 
lattice-like  opacity,  confined,  as  in  the  nodular  variety,  to  the  central 
part  of  the  cornea  and  to  its  anterior  layers.  The  hereditary  nature  of 
the  affection  was  first  pointed  out  by  Haab,42  who  met  with  it  in  a  lad 
aged  sixteen,  and  also  in  his  maternal  aunt  and  uncle.  Dimmer  re- 
corded three  cases  in  two  brothers  and  a  sister.  Freund43  described 
15  cases  in  two  families — seven  in  one  and  eight  in  the  other,  in  four 
generations. 

That  the  two  forms  of  hereditary  degeneration  of  the  cornea,  the 
nodular  and  the  lattice-like,  are  really  only  different  manifestations 
of  the  same  affection,  was  demonstrated  by  Doyne  and  Stephenson,44 
who  wrote  as  follows:  "The  two  diseases,  then,  agree- in  several  par- 
ticulars— as,  for  example,  that  they  begin  at  about  the  period  of 
puberty;  that  they  are  accompanied  by  insignificant  signs  of  inflam- 
mation; that  they  are  slowly  progressive;  that  they  probably  repre- 
sent not  an  inflammatory  but  a  degenerative  process.  Then,  lastly, 
there  is  the  fact  that  the  sensitiveness  of  the  cornea,  particularly  as 
regards  the  central  region,  may  be  impaired;  and,  finally,  that  both 
conditions  tend  to  run  in  families."  They  record  seven  cases  of  bi- 
lateral central  degeneration  of  the  cornea  in  three  generations  of  a 
family ;  in  some  of  these  cases  the  disease  belonged  to  the  lattice-like 
and  in  others  to  the  nodular  variety. 

It  will  be  seen,  then,  that  these  degenerative,  bilateral  diseases  of  the 
cornea  belong  to  the  same  class  of  ocular  affections  as  those  already  de- 
scribed in  this  paper,  and  correspond  with  those  degenerations  met 
with  in  other  parts  of  the  body,  attributed  by  Gowers  to  premature 
loss  of  vital  force,  or  abiotrophy.  The  pathologic  investigations  which 
have  been  made,  though  enabling  us  to  classify  the  disease  as  a  degen- 
eration, do  not  supply  us  with  sufficiently  definite  evidence  to  deter- 
mine in  which  structure  in  the  cornea  the  degeneration  primarily 
starts.  Two  points  in  the  clinical  history  of  these  affections  suggest 


Hereditary  Ocular  Degenerations  135 

that  possibly  the  nerves  of  the  cornea  might  be  the  primary  seat  of  the 
disease.  Fuchs,  in  describing  his  nodular  cases,  spoke  of  the  superfi- 
cial sensitiveness  of  the  cornea  being  lessened.  Jacqueau  described 
a  family  in  which  eight  cases  of  lattice-like  variety  were  met  with,  and 
in  whom  the  sensibility  of  the  cornea  to  touch  was  diminished. 

It  would  seem  most  probable  that  an  opacity  occurring  in  a  number 
of  different  cases  in  the  form  of  a  meshwork,  the  lines  composing 
which,  by  focal  illumination,  look  like  glass  thread  (Haab),  or  birch- 
twig-like  branches  radiating  from  the  periphery  toward  the  center 
(Freund),  must  have  some  anatomic  basis.  It  is  clear,  from  the  de- 
scription of  the  cases,  that  these  lines  do  not  represent  tracks  left  by 
blood-vessels.  In  no  stage  of  the  disease  does  the  cornea  become  vas- 
cularized,  and  its  peripheral  parts  always  remain  clear  and  free  from 
lines.  Any  tracks  left  by  blood-vessels  would  necessarily  extend  out 
to  the  margin  of  the  cornea,  to  join  the  vessels  from  which  they  were 
originally  derived.  The  only  other  anatomic  structure  we  know  of  in 
the  cornea  presenting  the  appearance  of  branching  lines  is  its  nerve- 
fibers. 

The  most  recent  investigations  into  the  arrangement  of  the  nerve- 
fibers  in  the  cornea  are  those  of  Dogiel,45  who  adopted  a  method  of 
staining  them  with  methylene-blue.  According  to  him,  two-thirds 
of  the  nerve-trunks  which  enter  the  cornea  pass  into  the  anterior 
lamellas,  where  they  form  what  is  termed  the  primary  or  fundamental 
plexus;  the  remaining  third  are  distributed  to  the  posterior  layers. 
The  nerves,  from  which  the  central  portion  of  the  fundamental  plexus 
is  derived,  enter  the  cornea  at  a  deeper  level  than  those  which  consti- 
tute its  peripheral  parts.  The  fundamental  plexus  is  composed  of  a 
network  of  fibers  in  the  anterior  layers  of  the  stroma,  where  the  fibers 
meet,  forming  nodal  points  at  which  nuclei  are  often  to  be  seen;  these 
are  now  regarded  as  belonging  to  the  delicate  investing  sheaths  of  the 
nerves,  and  not,  as  formerly,  to  ganglion-cells.  The  spaces  left  be- 
tween the  fibers  are  traversed  by  interlacing,  delicate  fibrils.  From 
the  fundamental  plexus  fibers  pass  forward,  through  channels  in  Bow- 
man's  membrane,  and  on  its  outer  surface  form  the  subepithelial 
plexus.  From  the  subepithelial  plexus  fibrillse  pass  in  between  the 
epithelial  cells,  terminating  either  as  round  or  pyriform  end-bulbs  or 
as  terminal  fibrillse.  The  fibrillse  of  the  fundamental  plexus,  lying 
between  the  lamellae  of  the  cornea,  come  into  close  relation  with  the 
corneal  corpuscles,  and  it  has  been  a  matter  of  much  discussion  as 
to  whether  or  not  there  is  any  direct  continuity  between  the  cells  and 
the  fibrillse. 


136  E.  TREACHER  COLLINS 

A  comparison  of  this  description  of  the  corneal  nerves  with  the  dis- 
tribution of  the  opacities  in  the  cases  of  hereditary  degeneration  of 
the  cornea  suggests  much  similarity  of  arrangement.  The  nerve-fibers 
form  a  plexus  in  the  anterior  layers  of  the  substantia  propria,  a  sub- 
epithelial  plexus,  and  terminate  in  end-organs  situated  among,  the 
epithelial  cells.  In  hereditary  degeneration  the  pathologic  changes 
are  found  in  the  same  situations.  The  central  part  of  the  fundamental 
plexus  and  of  the  subepithelial  plexus,  which  latter  is  constituted  of 
fibers  derived  from  the  former,  take  origin  from  different  nerve- 
trunks  to  those  from  which  the  peripheral  parts  of  these  plexuses  pro- 
ceed. Hereditary  degeneration  of  the  cornea  is  confined  to  the  central 
part,  and  there  also  anesthesia  is  noted  to  have  been  most  marked,  i.  e., 
in  a  region  which  receives  its  nerve  supply  from  one  set  of  nerves.  The 
fundamental  plexus  is  composed  of  a  network  of  fibers  crossing  and 
intersecting  one  another,  similar  in  appearance  to  the  arrangement  of 
the  lines  of  opacity  met  with  in  the  lattice-like  type  of  hereditary  de- 
generation of  the  cornea. 

In  hereditary  degenerations  of  nervous  structures  in  other  parts  of 
the  body,  associated  with  the  atrophy  of  the  nervous  tissue,  there  are 
always  changes  in  the  surrounding  supporting  fibrous  tissue.  If, 
as  I  suggest,  this  hereditary  degeneration  of  the  cornea  is  a  primary 
dystrophy  of  its  nerve-fibers  and  nerve  end-organs,  then  we  should  ex- 
pect to  meet  with  thickening  of  the  neuroglia  tissue  surrounding  the 
nerves,  some  hyaline  degeneration  in  it,  and  a  formation  of  spaces 
filled  with  coagulum  representing  those  previously  filled  by  the  nerve 
tissue.  These  changes  resemble  those  which  have  been  described  as 
met  with  in  cases  of  nodular  degeneration  of  the  cornea.  It  is  possible 
that  the  different  appearances  in  the  arrangement  of  the  opacity, which 
has  been  met  with  clinically  in  these  diseases,  may  be  accounted  for 
by  a  difference  in  the  part  of  the  nervous  system  of  the  cornea  which 
is  primarily  attacked.  For  instance,  if  it  started  in  the  fundamental 
plexus  in  the  substantia  propria,  we  should  expect  the  opacity  in  the 
first  instance  to  be  of  the  lattice-like  variety;  whereas  if  it  started  in 
the  end-organs  in  the  epithelium,  we  should  expect  it  to  start  in  the 
form  of  opaque  dots  or  nodules. 

For  any  final  decision  as  to  the  primary  seat  of  this  disease,  further 
research  is  necessary.  I  would  suggest  that  the  employment  of 
Dogiel's  method  of  methylene-blue  staining  to  a  fragment  of  an 
affected  cornea,  removed  either  by  scraping  or  by  trephining,  might 
be  of  considerable  assistance  in  clearing  up  the  problem. 


Hereditary  Ocular  Degenerations  137 

TREATMENT 

In  dealing  with  the  treatment  of  these  various  forms  of  hereditary 
ocular  degeneration  it  is  first  well  to  point  out  that  a  medical  man  is 
called  upon  to  certify  that  life  is  extinct,  as  well  as  to  prescribe  reme- 
dies for  various  ailments.  Every  medical  student  has  to  learn  the 
signs  of  death  in  an  individual,  so  it  is  well  for  an  ophthalmic  surgeon 
to  learn  to  recognize  the  signs  of  death  in  a  tissue  of  that  organ  of  the 
body  with  which  he  specially  deals. 

The  recognition  that  these  maladies  are  due  to  premature  death  of 
the  tissues  involved  does  not  offer  much  hope  for  their  alleviation  by 
therapeutic  measures.  It  may,  however,  save  us  from  trying  to  revivify 
dead  matter  by  iodid  of  potassium,  vapor  baths,  or  other  measures  of 
that  description,  which  only  raise  illusive  hopes  in  our  patients,  cause 
needless  expenditure  of  money  on  their  part,  and  are  doomed  to  failure. 

Bichat  defined  life  as  "the  sum  of  the  forces  which  resist  death,"  and 
though,  like  all  other  definitions  of  life  which  have  been  attempted, 
it  leaves  something  to  be  desired,  it  is  useful  in  connection  with  the 
subject  now  under  consideration.  One  of  the  forces  which  resist 
death  is  inherent,  and  varies  in  its  duration  and  degree.  Though  at 
some  future  date  it  may  be  accounted  for  by  physicochemical  changes, 
at  present  we  know  too  little  concerning  it  to  attempt  to  control  it. 
Other  forces  which  resist  death  are  connected  with  the  environment 
of  the  organism  or  of  its  tissues.  It  is  essential  that  it  should  have  an 
adequate  and  suitable  supply  of  nutrient  material.  If  the  vital  force 
in  a  tissue  is  inherently  weak,  the  adequate  supply  of  suitable  nutrient 
material  may  delay  its  final  extinction;  which,  on  the  other  hand, 
might  be  accelerated  by  the  presence  of  toxic  substances  in  the  fluids 
in  which  the  tissue  is  bathed.  In  these  hereditary  degenerations,  to 
delay  the  failure  of  vital  force  by  maintenance  of  nutrition,  and  to  re- 
move any  source  of  toxemia,  is  all  we  can  hope  to  effect  by  medicinal 
measures.  In  some  of  the  affections  dealt  with  operative  procedures 
may  alleviate  some  of  the  inconvenience  caused  by  them.  Thus 
abiotic  cataracts  can  be  removed  and  the  sight  restored.  In  bilateral 
ptosis,  the  removal  of  a  strip  of  the  tarsal  plate  will  do  away  with 
much  of  the  discomfort  which  drooping  of  the  eyelid  gives  rise  to. 
In  cases  of  retinitis  pigmentosa  trephining  operations,  by  producing  a 
state  of  hypotony,  have  caused  dilatation  of  the  retinal  vessels,  and 
tended  to  delay  the  atrophic  process.  In  some  cases  of  nodular  opacity 
of  the  cornea  its  anterior  layers  have  been  scraped  away  or  excised 
by  a  trephine,  with  some  slight  improvement  of  sight. 


138  E.  TREACHER  COLLINS 

REFERENCES 

1.  Cowers,  Sir  William:  The  Lancet,  April  12,  1902. 

2.  Cowers,  Sir  William:  Brit.  Med.  Jour.,  July  12,  1902. 

3.  Paget,  Sir  James :  Lectures  on  Surgical  Pathology,  4th  Ed.,  1876,  pp.  70  and  72. 

4.  Metchnikoff,  E.:  The  Prolongation  of  Life.     Eng.  Trans.,  1907. 

5.  Nettleship,  E.:   Bowman  Lecture,  Trans.  Ophth.  Soc.  U.  K.,  1909,  xxix. 

6.  Collins,  E.  Treacher:  Trans.  Ophth.  Soc.  U.  K.,  1915,  xxxv,  371. 

7.  Fuchs,  E. :  Arch.  f.  Ophth.,  1890,  xxxvi,  i,  234. 

8.  Collins,  E.  Treacher:  Trans.  Ophth.  Soc.  U.  K.,  1909,  xxix,  225. 

9.  Beaumont,  W.  M.:  Trans.  Ophth.  Soc.  U.  K.,  1900,  xx,  258. 

10.  McMullen  and  Hine:  Brit.  Jour.  Ophth.,  1921,  v,  337. 

11.  Wilbrand  and  Saenger:  Neurologic  des  Auges,  1900,  i,  117. 

12.  Ayres:  Amer.  Jour.  Ophth.,  1896. 

13.  Altland:  Arch.  Ophth.,  1909,  296. 

14.  Heuck:  Klin.  Monats.  f.  Augenh.,  1879,  xvii,  253. 

15.  Lawford,  J.  B.:  Trans.  Ophth.  Soc.  U.  K.,  1888,  viii,  262. 

16.  Collins,  E.  Treacher:  Trans.  Ophth.  Soc.  U.  K.  1919,  xxxix,  165. 

17.  Nettleship,  E.:  Roy.  Lond.  Ophth.  Hosp.  Rep.,  1907-8,  xvii. 

18.  Wagenmann:  Arch.  f.  Ophth.,  1891,  xxxvi,  iv. 

19.  Lister,  Sir  William:    Roy.  Lond.  Ophth.  Hosp.  Rep.,  xv,  258. 

20.  Stock,  W.:   Klin.  Monats.  f.  Augenh.,  1908,  xlvi,  225. 

21.  Ginsberg:   Klin.  Monats.  f.  Augenh.,  1908,  xlvi,  1. 

22.  Suganama:  Klin.  Monats.  f.  Augenh.,  1912,  1,  175. 

23.  Batten,  Dr.  F.  E.,  and  Mayou,  M.  S.:   Proc.  Roy.  Soc.  Med.,  Ophth.  Sec., 

viii,  70. 

24.  Coats,  G.:  Proc.  Roy.  Soc.  Med.,  Ophth.  Sec.,  1916,  ix,  219. 

25.  Holmes,  Dr.  Gordon:  Brain,  1906,  xxix. 

26.  Mott,  Sir  Frederick:  Arch.  Neurol.,  1907,  iii,  219. 

27.  Sachs,  B.:  Jour.  Nerv.  and  Ment.  Dis.,  1903,  xxx,  1. 

28.  Leber:  Arch.  f.  Ophth.,  1871,  xvii. 

29.  Gowers,  Sir  William:   Medical  Ophthalmoscopy,  4th  Ed.,  1904,  283. 

30.  Fisher,  J.  H.:  Trans.  Ophth.  Soc.  U.  K.,  1916,  xxxvi,  298. 

31.  Fisher,  J.  H.:  Trans.  Ophth.  Soc.  U.  K.,  1917,  xxxvii,  251. 

32.  Pollock,  W.  B.:  Trans.  Ophth.  Soc.  U.  K.,  1917,  xxxvii,  247. 

33.  Taylor,  Dr.  James:  Brit.  Jour.  Ophth.,  1919,  iii,  193. 

34.  Doyne,  R.  W.:  Trans.  Ophth.  Soc.  U.  K.,  1899,  xix,  71;   1910,  xxx,  274. 

35.  Mould,  Major  G.  T.:  Trans.  Ophth.  Soc.  U.  K.,  1910,  xxx,  189. 

36.  Collins,  E.  Treacher:  Ophthalmoscope,  1913,  ix,  537. 

37.  Groenouw:  Arch.  f.  Ophth.,  1898,  xlvi,  85;  Arch.  Ophth.,  1890,  245. 

38.  Gunn,  Marcus:  Trans.  Ophth.  Soc.  U.  K.,  1902,  xxii,  97. 

39.  Spicer,  W.  Holmes:  Trans.  Ophth.  Soc.  U.  K.,  1904,  xxiv,  42. 

40.  Paderstein,  R.:  Klin.  Monats.  f.  Augenh.,  1909,  xlvii,  159. 

41.  Fuchs,  E.:  Arch.  f.  Ophth.,  1915,  Ixxxix,  ii. 

42.  Haab:  Zeitschr.  f.  Augenh.,  1890,  235. 

43.  Freund:   Arch.  f.  Ophth.,  1903,  Ixxxvii,  377. 

44.  Doyne  and  Stephenson:   The  Ophthalmoscope,  1905,  iii,  213. 

45.  Dogiel:  Anatom.  Anzeiger,  1890,  v,  No.  16. 


Hereditary  Ocular  Degenerations  139 

DISCUSSION 

PROF.  C.  E.  FINLAY  (Havana,  Cuba):  In  connection  with  Mr.  Collins' 
interesting  paper  I  want  to  state  that  in  Cuba  I  have  had  opportunity  of 
observing  a  good  many  of  these  cases.  Congenital  cataract  is  frequent;  also 
retinitis  pigmentosa,  post-natal  cataract,  and  the  lattice-like  degeneration. 
In  most  of  these  cases  we  have  been  able  to  see  a  certain  amount  of  hereditary 
influence.  That  is  especially  marked  in  retinitis  pigmentosa  and  post-natal 
cataract. 

We  have  a  province  in  Cuba  which  before  we  had  railroads  was  completely 
isolated,  and  there  we  have  had  a  number  of  intermarriages  in  the  same 
family,  cousins  marrying  cousins,  uncles  marrying  nieces,  etc.,  so  that  the 
number  of  cases  of  congenital  cataract  is  greater  there  than  in  the  rest  of 
the  island.  In  one  family  cataract  was  observed  in  seven  different  mem- 
bers. In  this  same  province  a  Chinaman  married  a  white  woman,  and 
they  had  six  children,  five  of  whom  had  congenital  cataract.  As  regards 
the  lattice-like  and  nodular  opacities,  I  have  been  able  to  observe  them  in 
the  same  family.  I  remember  a  mother,  three  daughters,  and  a  niece,  all  of 
whom  had  the  nodular  variety  or  the  lattice-like  opacities.  In  all  of  these 
cases  it  was  limited  to  the  female  members  of  the  family. 

DR.  F.  H.  VERHOEFF  (Boston,  Mass.):  The  term  "abiotrophy,"  I  take  it, 
implies  something  inherent  in  the  cell  which  causes  it  to  die,  irrespective  of  any 
external  influence.  It  seems  to  me  that  the  term  has  no  advantage  over  the 
term  with  which  we  are  more  familiar,  and  that  is  "premature  senility." 
The  term  "premature  senility"  would  not  necessarily  mean  immediate  de- 
generation, and  we  know  that  senile  changes  do  not  always  consist  of  death  of 
the  cells,  but  sometimes  of  hyperplasia.  Mr.  Collins'  hypothesis  is  an  attrac- 
tive one  as  regards  senile  cataract.  In  cataracts  definitely  known  to  be  due 
to  disturbance  of  nutrition  the  opacities  are  different  from  those  in  senile 
cataracts.  They  begin  in  the  posterior  cortex  whereas  those  of  senile  cata- 
racts begin  as  peripheral  strise.  A  typical  senile  lens,  however,  is  a  sclerosed 
lens,  hence  a  senile  cataract  does  not  represent  premature  senility  of  the  lens 
as  a  whole.  We  do,  however,  occasionally  see  sclerosed  lenses  in  younger 
people.  I  recently  saw  a  man  of  fifty  who  had  a  sclerosed  lens  such  as  you 
would  expect  in  a  man  of  seventy  or  eighty. 

In  regard  to  Doyne's  choroiditis,  I  understand  Mr.  Collins  regards  this  as 
an  exaggerated  form  of  Tay's  choroiditis.  The  changes  in  this  are  primarily 
proliferative  in  nature;  they  indicate  not  merely  death  of  the  cells,  but  that 
the  pigment  cells  undergo  proliferation.  The  hyaline  material  I  think  is 
produced  by  secretion  of  the  cells,  as  Coats  pointed  out.  So  in  this  condition 
you  see  the  term  "premature  senility"  would  be  better  than  "abiotrophy." 

In  regard  to  the  treatment  of  some  of  these  conditions  I  should  like  to 
suggest  that  it  would  be  well  to  try  the  x-ray.  We  know  that  the  latter  in 
weak  doses  will  stimulate  resting  cells,  and  in  stronger  doses  will  destroy  pro- 
liferative cells.  About  a  year  ago  I  began  to  employ  it  in  retinitis  pigmentosa. 
A  sufficient  time  has  not  elapsed  to  tell  whether  or  not  it  has  been  of  real 
benefit,  but  it  certainly  has  done  no  harm.  The  difficulty  has  been  to  decide 
upon  the  dosage  and  frequency  of  exposure. 


140  E.  TREACHER  COLLINS 

DR.  E.  E.  BLAAUW  (Buffalo,  N.Y.):  Since  the  previous  Congress  we  have 
made  certain  advances  in  our -knowledge  of  the  formation  of  cataract,  and  I 
think  the  term  "abiotrophy  "  is  an  excellent  one. 

The  first  lenticular  changes  appear  at  the  age  of  twenty.  If  we  dilate  the 
pupils,  we  will  find  spots  in  20  per  cent,  of  eyes,  which  will  increase  in  extent 
and  intensity  and  progress  to  senile  cataract.  The  changes  appear  in  the 
cortex,  at  the  place  where  outer  and  middle  third  of  the  radius  meet  (the 
coronary  cataract  of  Vogt).  With  the  slit  lamp  also  can  be  demonstrated 
convincingly  that  these  earlier  cortical  opacities  do  not  appear  directly  below 
the  capsule  but  always  at  a  certain  distance  away  from  it.  As  a  rule,  senile 
cataract  does  not  begin  in  the  posterior  cortex. 

I  agree  with  Mr.  Collins  that  in  many  of  these  cases  we  find  heredity 
plays  an  important  role. 

DR.  GEORGE  F.  LIBBY  (Denver,  Col.) :  We  owe  much  to  Edward  Nettle- 
ship  and  his  colleagues  for  putting  the  subject  of  ocular  heredity  on  such  a 
firm  foundation;  and  I  think  it  is  a  very  happy  circumstance  that  one  of 
Nettleship's  co-workers  should  bring  before  us  this  notable  paper.  Reading 
Mr.  Collins'  paper  carefully  in  the  presession  volume  I  felt  that  at  last  we 
had  a  nomenclature  that  was  satisfactory.  I  have  not  been  fully  satisfied 
with  the  rather  hazy  terms  we  have  used  in  describing  this  condition. 

In  reading  the  conclusions  of  the  paper  I  felt  that  a  little  more  hope  was 
held  out  in  the  matter  of  hereditary  degeneration — perhaps  more  than  the 
author  has  indicated  in  the  summary  of  his  paper  just  presented.  At  any 
rate,  we  get  a  definite  idea  as  to  what  is  actually  hopeless,  and  what  we  may 
so  represent  to  our  patients.  It  seems  to  me  that  in  the  conditions  which 
Mr.  Collins  has  described  we  should  look  out  particularly  for  the  hygiene  of 
such  patients.  I  think  they  deserve  a  little  more  care,  direction,  counsel, 
and  caution  along  hygienic  lines  than  the  majority  of  patients. 

DR.  EDWARD  JACKSON  (Denver,  Col.) :  I  feel  that  Mr.  Collins  has  done  us  a 
real  service  in  tracing  the  line  of  communication  between  the  widely  separ- 
ated individual  conditions  that  he  has  grouped,  such  as  ptosis,  ophthalmo- 
plegia,  Leber's  disease,  pigmentary  degeneration  of  the  retina,  and  others  that 
we  have  thought  of  separately,  not  connected  with  each  other.  He  certainly 
has  given  a  new  view  with  reference  to  these  conditions,  although  the  new 
view  that  we  first  get  may  be  different  from  the  final  view. 

There  are  two  or  three  points  that  I  think  are  illustrated  in  the  discussion. 
One  of  them  has  just  been  referred  to,  and  that  is  the  hopelessness.  It  has 
always  been  assumed  that  death  of  tissue  is  a  hopeless  condition.  It  is  hope- 
less after  it  has  occurred,  but  the  family  tendency  in  that  direction  need  not 
by  any  means  be  hopeless,  and,  as  I  think  Mr.  Collins  mentioned,  and  as  the 
last  speaker  has  indicated,  it  is  rather  an  incentive  to  study  more  closely  the 
conditions  which  hasten  or  retard  the  death  of  the  tissue  in  premature  senility, 
or  abiotrophy. 

As  to  the  connection  between  heredity  and  these  affections,  I  can  conceive 
that  as  the  somatic  death  of  the  individual  is  hastened  or  retarded  by  certain 
influences,  so  the  tendency  to  early  death  of  the  cell  tissue,  a  degeneration  that 
is  not  hereditary,  may  be  so  influenced.  There  may  be  a  tendency  to  early 


Hereditary  Ocular  Degenerations  141 

death  of  certain  tissues  of  the  eye,  but  that  does  not  entirely  remove  retinitis 
pigmentosa  from  syphilitic  disease.  They  are  often  confused,  and  the 
syphilis  may  have  been  the  cause  in  one  patient,  of  tendencies  that  are  similar 
to  the  hereditary  tendencies  of  another  patient.  In  this  connection  I  wish  to 
refer  to  Leber's  disease.  It  has  been  assumed  very  generally  that  it  is  a 
primary  disease  of  the  optic  nerve  in  patients  with  a  hereditary  tendency. 
One  case  that  I  saw  about  thirty  years  ago  (the  only  case  I  have  ever  seen  in 
the  beginning),  and  that  I  have  heard  from  within  a  very  few  years,  has  gone 
through  his  life  giving  the  ordinary  history  of  hereditary  optic  atrophy.  That 
patient  entirely  deceived  me  by  lying  about  his  family  history,  but  one  of  my 
colleagues  knew  the  family  and  quickly  traced  the  history — he  knew  the 
man's  ancestors  had  been  similarly  affected,  so  that  with  the  subsequent 
course  of  the  case  I  was  able  to  place  it  in  that  connection.  That  case  illus- 
trated the  fact  that,  even  if  we  have  not  an  enucleated  eyeball  to  study  with 
the  microscope,  we  have  the  facilities  to  study  the  living  eye  with  the  ophthal- 
moscope. In  that  case  the  patient  ran  through  a  course  of  central  retinitis 
with  some  small  hemorrhages,  not  marked,  confined  entirely  to  the  macula, 
and  ending  with  an  atrophy  of  the  optic  nerve  corresponding  to  this  central 
scotoma,  with  no  visible  change  in  the  macula  after  the  first  few  weeks  or 
months.  Now  I  can  conceive,  taking  that  for  an  illustration,  that  some 
temporary  condition  to  which  that  family  undoubtedly  was  extremely  sensi- 
tive may  have  appeared  in  that  young  man  to  start  a  local  process  in  the 
retina  which  gave  the  picture  of  Leber's  atrophy. 

So,  while  we  have  connected  these  different  conditions  with  tissue  death, 
and  that  is  right,  yet  I  think  treatment  is  valuable.  It  does  not  render  them 
hopeless,  and  it  gives  to  us  not  only  a  good  ground  for  prognosis,  but  leaves  us 
a  wide  field  for  study,  with  the  hope  that  in  the  future  the  family  perhaps 
may  benefit  from  our  labors. 

DE.  MARY  BUCHANAN  (Philadelphia) :  About  1904,  a  Hebrew  woman  who 
had  retinitis  pigmentosa,  brought  her  infant  with  amaurotic  family  idiocy  to 
the  Polyclinic  Hospital.  The  child  died  of  pneumonia  and  the  mother  dis- 
appeared, so  it  was  impossible  to  follow  up  the  history. 

In  another  case,  a  child  had  been  under  treatment  in  the  nervous  clinic  of 
the  University  Hospital  for  spastic  diplegia  due  to  hereditary  lues.  As  there 
was  no  thought  of  an  eye  condition,  the  child  was  not  referred  to  the  eye 
clinic.  The  Wassermann  was  faintly  positive  for  the  baby  and  the  father; 
the  mother's  was  negative.  The  child  was  given  mercury  but  did  not  im- 
prove. I  saw  the  patient  when  two  years  five  months  old.  The  macular 
picture  was  lacking,  and  the  vessels  were  almost  normal  in  size,  but  the  discs 
were  white.  The  child  was  blind  and  idiotic.  The  spasticity  of  the  lower 
limbs  persisted,  although  the  rest  of  the  body  was  flaccid.  A  second  child, 
then  six  months  old,  was  healthy. 

DR.  WILLIAM  EVANS  BRUNER  (Cleveland,  Ohio) :  I  desire  to  add  merely  a 
few  words  in  regard  to  one  point  brought  out  by  Mr.  Collins — x-ray  exami- 
nation in  hereditary  optic  atrophy.  The  essayist  refers  to  the  work  of  Mr. 
Fisher  along  this  line.  His  results  were  first  published  in  1916.  In  1912,  or 
four  years  earlier,  I  read  a  paper  before  the  American  Ophthalmological 


142  E.  TREACHER  COLLINS 

Society  upon  "Hereditary  Optic  Atrophy,  with  X-ray  Findings."1  The  paper 
pretends  to  give  no  new  theorj',  but  does  show  some  points  of  interest  and 
especially  one — the  x-ray  findings  which  suggest  the  advisability  of  future 
study  along  this  line  in  other  cases  of  the  same  and  allied  diseases. 

The  patient,  a  man  aged  thirty-six,  was  seen  by  Dr.  de  Schweinitz,  who  con- 
curred in  the  diagnosis  and  wrote:  "I  do  not  recall  that  I  have  before  x-rayed 
a  patient  with  this  type  of  optic  nerve  atrophy,  but  certainly  the  stereoscopic 
x-ray  plates  show  marked  thickening  either  in  the  sphenoid  region  or  in  the 
neighborhood  of  the  sella,  and  it  occurs  to  me  that  this  lesion,  whatever  it  may 
be,  has  something  to  do  with  the  optic  nerve  disease." 

Dr.  Spiller,  of  Philadelphia,  made  a  neurologic  examination,  confirmed  the 
diagnosis  and  adds:  "The  x-rays  show  a  projection  upward  of  the  floor  of  the 
sella  turcica  and  suggest  that  the  pituitary  body  may  have  its  function 
impaired  in  this  way.  I  do  not  know  in  how  many  cases  of  family  optic 
atrophy  x-ray  plates  have  been  made." 

X-ray  plates  were  made  of  a  sister  who  had  the  disease  and  of  a  nephew  who 
from  the  history  also  probably  had  it.  By  way  of  comparison,  plates  were 
made  also  of  his  mother  and  a  sister  who  did  not  have  the  disease,  and  their 
plates  showed  nothing  abnormal. 

Later  he  saw  Dr.  Harvey  Gushing,  who  also  agreed  with  the  diagnosis, 
though  the  subsequent  history  would  indicate  that  it  was  an  atypical  case. 

I  closed  the  paper  with  the  "hope  that  other  patients  presenting  similar 
symptoms  may  be  subjected  to  like  x-ray  examinations."  I  have  not  had  the 
opportunity  of  seeing  another  case  of  this  disease  since  that  time  and  have 
naturally  been  much  interested  in  the  results  of  such  examinations  by  other 
observers. 

MR.  E.  TREACHER  COLLINS  (closing) :  First  of  all  I  would  like  to  congratu- 
late Prof.  Finlay  on  having  such  a  fine  field  for  pathologic  investigation  of 
hereditary  diseases  as  Cuba.  I  hope  we  may  soon  hear  from  him  of  a  case  of 
hereditary  optic  atrophy  on  which  he  has  been  able  to  perform  a  pathologic 
examination.  I  am  also  interested  in  his  cases  of  degeneration  of  the  cornea 
in  which  some  members  had  the  nodular  and  others  the  lattice-like  type. 
That  helps  to  confirm  the  theory  that  the  two  are  but  different  manifestations 
of  the  same  affection. 

Dr.  Verhoeff  takes  exception  to  the  term  "abiotrophy" — he  prefers  "pre- 
mature senility."  Premature  senility  seems  to  me  to  imply  something  to  do 
with  old  age,  while  some  of  the  cases  I  brought  before  you  began  quite  early 
in  life,  for  instance,  the  amaurotic  family  idiocy.  It  does  not  seem  correct 
to  speak  of  senility,  even  premature  senility,  in  connection  with  a  disease 
beginning  early  in  life.  Again,  the  term  "abiotrophy"  goes  farther  and  gives 
more  the  idea  that  Sir  William  Gowers  had  in  mind  in  using  it — that  is,  a  loss 
of  some  vital  energy.  Dr.  Verhoeff  also  takes  exception  to  the  hyaline  sub- 
stance met  with  on  the  inner  surface  of  the  choroid  being  regarded  as  a  degen- 
eration. He  regards  it  as  due  to  proliferation.  The  condition  is  most  cer- 
tainly a  degeneration  in  function  even  if  the  cells  do  not  absolutely  perish. 

1  Trans.  American  Ophthalmological  Society,  1912;  and  Archives  of  Ophthal- 
mology. 1912,  vol.  xl,  p.  435. 


Hereditary  Ocular  Degenerations  143 

Dr.  Blaauw,  I  am  glad  to  hear,  agrees  with  me  in  liking  the  term  "abio- 
trophy."  He  also  agrees  that  the  senile  cataract  begins  in  the  cortex. 

Dr.  Libby  says  the  recognition  of  these  cases  helps  us  in  our  statements  to 
patients.  I  quite  agree  with  that.  Since  I  came  to  regard  these  cases  from 
my  present  point  of  view  it  had  given  me  much  confidence  in  speaking  to 
patients  as  to  prognosis  and  of  those  precautionary  measures  they  should  take 
in  regard  to  nutrition,  etc.  I  feel  I  can  speak  with  more  confidence. 

Dr.  Jackson  compared  retinitis  pigmentosa  with  a  syphilitic  choroido- 
retinitis.  They  are  often  very  similar  ophthalmoscopically.  We  know  that 
in  syphilitic  choroiditis  the  primary  change  is  vascular;  it  is  a  change  in  the 
capillary  layers  producing  secondary  degeneration  of  the  rods  and  cones,  not 
a  primary  degeneration  of  those  structures.  I  congratulate  Dr.  Jackson  on 
his  optimistic  outlook  in  treatment  of  these  conditions. 

I  think  Dr.  Buchanan's  case  must  have  been  one  of  amaurotic  family  idiocy 
from  the  account  she  gives  of  it. 

Dr.  Bruner  spoke  of  z-ray  findings  in  a  case  of  hereditary  optic  atrophy. 
I  quote  a  number  of  cases  in  my  paper,  and  have  learned  from  Dr.  Zentmayer 
that  he  also  reported  a  case,  some  of  them  with  slight  changes,  and  others 
without.  In  cases  of  abiotrophy  we  should  expect  overgrowth  of  fibrous 
tissue.  The  changes  seen  in  the  x-ray  picture  might  be  due  to  a  thickening  of 
the  chiasma  pressing  down  on  the  pituitary  body  instead  of  the  pituitary  body 
pressing  up  on  the  chiasma. 


BITEMPORAL  CONTRACTION  OF  VISUAL  FIELDS 
IN  PREGNANCY 

PROF.  C.  E.  FINLAY 

Havana,  Cuba 

On  February  15,  1919,  a  case  was  sent  to  me  in  consultation  which 
gave  rise  to  the  investigations  which  form  the  subject  of  this  paper. 
Its  clinical  history  was  as  follows: 


L.  E. 


Fig.  L— E.  P.  M.,  February  15,  1919. 

Mrs.  E.  P.  M.,  aged  twenty-four  years,  a  leading  society  lady,  in  the 
eighth  month  of  pregnancy,  had  suffered  a  month  previously  a  severe  attack 
of  influenza.  After  recovery  she  had  developed  a  series  of  seizures  of  a 
cataleptic  nature,  during  which  she  could  not  move,  though  perfectly  con- 
scious of  what  was  going  on  around  her.  My  examination  of  her  eyes  re- 
sulted as  follows: 

Corneae  and  conjunctivse  normal. 

Media  clear. 

Pupillary  reactions  normal. 

Fundi:    Slight  contraction  of  retinal  arteries  and  dilatation  of  retinal 

veins. 

Visual  acuity  (each),  20/20. 

Visual  fields:  Temporal  contraction  (more  pronounced  on  right  side) 
for  white,  with  marked  concentric  contraction  for  colors,  the  red 
field  being  larger  than  that  for  blue,  there  being  also  a  crossing  of  the 
limits  of  the  color  fields  on  the  left  side  (Fig.  1). 

144 


Bitemporal  Contraction  of  Visual  Fields  in  Pregnancy         145 

I  concluded  that  there  exists  a  hypophyseal  compression  of  the 
chiasm,  but  was  at  a  loss  as  to  whether  this  was  due  to  a  hypophyseal 
tumor  or  to  an  enlargement  of  the  hypophysis  in  connection  with  preg- 
nancy, and  as  to  whether  the  cataleptic  seizures  were  due  to  the  en- 
largement of  the  hypophysis  or  of  a  hysteric  nature.  The  further 
history  of  this  case  has  no  particular  bearing  on  this  paper.  The 
seizures  continued  after  confinement,  and  some  of  the  experts  who 
later  saw  the  patient  thought  there  was  some  endocrinic  disturbance 
with  hysteric  manifestations.  But  the  study  of  the  case  made  me 
seek  to  determine  whether  the  normal  hypertrophy  of  the  pituitary 
body  which  takes  place  in  connection  with  pregnancy  was  of  such  a 


R.E. 


Fig.  2.— Case  I.     E.  E.,  July  10,  1920. 

degree  as  to  determine  changes  in  the  visual  fields.  Through  the 
courtesy  of  Professor  Bustamante,  in  charge  of  the  Maternity  Clinic 
of  the  General  Calixto  Garcia  Hospital,  I  proceeded  to  examine  the 
visual  fields  of  a  number  of  women  awaiting  confinement,  selecting 
only  cases  that  presented  no  general  complications,  with  normal  eye- 
grounds  and  perfect  visual  acuity. 

The  following  are  the  reports  of  the  31  cases  examined: 

CASE  I. — E.  E.,  white,  aged  twenty,  Cuban.     Pregnancy,  eight  months. 
Urine  normal. 
Fundi  normal. 
Visual  acuity,  2Q  /20. 

Visual  fields:    Marked  contraction — more  marked  in  temporal  half; 
more  pronounced  on  left  side  (Fig.  2). 

10 


146 


C.  E.  FlNLAY 


CASE  III. — J.  F.,  Cuban,  mulatto,  aged  thirty-six.     Nine  months  pregnant. 

Urine:    No  albumin;  specific  gravity  1000. 

Visual  acuity  (each),  20/20. 

Visual  fields:  Marked  bitemporal  contraction  (Fig.  3).  This  patient 
had  a  normal  labor  on  August  16,  1920,  and  a  second  examination 
ten  days  later  showed  a  slight  reduction  in  the  bitemporal  defects. 


L.  JB.      12 


R.E. 


Fig.  3.— Case  III.     J.  F.,  July  10,  1920. 

CASE  IV. — L.  A.,  Cuban,  negress,  aged  sixteen.    Nine  months  pregnant. 
Urine:  No  albumin;  specific  gravity  1011. 
Fundi  normal.     Visual  acuity  (each),  20/20. 
Visual  fields:  Marked  bitemporal  contraction  (Fig.  4). 


R.E 


Fig.  4.— Case  IV.    L.  A.,  July  13,  1920. 


Bitemporal  Contraction  of  Visual  Fields  in  Pregnancy         147 

CASE  VII. — C.  C.,  Cuban,  mulatto,  aged  twenty-nine.     Eight  months 

pregnant. 

Urine:  Trace  albumin;  specific  gravity  1020. 
Fundi  normal.    Visual  acuity  (each),  20/20. 

Visual   fields:     Very   pronounced    concentric    contraction,    greater   in 
temporal  half  (Fig.  5). 


L.  &. 


Fig.  5.— Case  VII.     C.  C.,  July  19,  1920. 

CASE  VIII. — C.  V.,  Cuban,  mulatto,  aged  thirty-seven.     Nine  months 

pregnant. 

Urine:  No  albumin;  specific  gravity  1031. 
Fundi  normal.     Visual  acuity  (each),  20/20. 
Visual  fields:  Marked  bi temporal  contraction  (Fig.  6). 


fLK 


Fig.  6.— Case  VIII.     C.  V.,  July  15,  1921. 


148 


C.  E.  FlNLAY 


CASE  X  — M.  C.,  white,  aged  thirty-eight.     Eight  months  pregnant. 
Urine:  No  albumin;  specific  gravity  1024. 
Fundi  normal.     Visual  acuity  (each),  20/20. 
Visual  fields:  Marked  bitemporal  contraction  (Fig.  7). 


L.  S. 120 


ft.£". 


Fig.  7.— Case  X.     M.  C.,  July  17,  1921. 

CASE  XI. — C.  G.,  Cuban,  mulatto,  aged  twenty-eight.     Eight  months 

pregnant. 

Urine:  No  albumin;  specific  gravity  1016. 
Fundi  normal.     Visual  acuity,  20/20. 
Visual  fields:  Moderate  bitemporal  contraction  (Fig.  8). 


L.S.      j, 


R.K 


Fig.  8.— Case  XI.     C.  G.,  July  17,  1921. 


Bitemporal  Contraction  of  Visual  Fields  in  Pregnancy         149 

CASE  XIII. — M.  C.,  Cuban,  white,  aged  eighteen.     Nine  months  pregnant. 
Urine:  Trace  albumin;  specific  gravity  1012. 
Fundi  normal.    Visual  acuity  (each),  20/30. 
Visual  fields:  Marked  bitemporal  contraction  (Fig.  9). 


L.  & 


R.K 


Fig.  9.— Case  XIII.     M.  C.,  July  22,  1921. 

CASE  XIV. — A.  L,  Cuban,  negress,  aged  seventeen.    Eight  months  preg- 
nant. 

Urine:  No  albumin;  specific  gravity  1012. 
Fundi  normal.     Visual  acuity  (each),  20/20. 
Visual  fields:  Moderate  bitemporal  contraction  (Fig.  10). 


L.  ff. 


R.E. 


210'  370" 

Fig.  10.— Case  XIV.     A.  L,  August  21,  1921. 


150  C.  E.  FlNLAY 

CASE  II. — J.  G.,  white,  Spanish,  aged  twenty-two.     Nine  months  pregnant. 

Urine:  No  albumin;  specific  gravity  1020. 

Fundi  normal. 

Visual  acuity  (each),  20/20. 

Visual  fields:  Practically  normal. 
CASE  V. — A.  G.,  Cuban,  negress,  aged  sixteen.    Seven  months  pregnant. 

Urine:  Trace  albumin;  specific  gravity  1015. 

Fundi  normal. 

Visual  acuity  (each),  20/20. 

Visual  fields:  Bitemporal  contraction. 
CASE  VI. — R.  G.,  Cuban,  white,  aged  twenty-one.     Nine  months  pregnant. 

Urine:  Trace  albumin;  specific  gravity  1023. 

Fundi  normal. 

Visual  acuity,  20/20. 

Visual  fields:  Very  slight  contraction  (R);  slight  contraction  (L). 
CASE  IX. — G.  S.,  Cuban,  negress,  aged  thirty-seven.     Nine  months  preg- 
nant. 

Urine:  No  albumin;  specific  gravity  1018. 

Fundi  normal. 

Visual  acuity  (each),  20/20. 

Visual  fields:  Moderate  bitemporal  contraction. 
CASE  XII. — M.  S.,  Cuban,  white,  aged  fourteen.     Five  months  pregnant. 

Urine:  Trace  albumin;  specific  gravity  1016. 

Fundi  normal. 

Visual  acuity  (each),  20/20. 

Visual  fields:    Slight  temporal  contraction   (R);    moderate  temporal 

contraction  (L). 
CASE  XV. — F.  A.,  white,  aged  twenty-three.     Nine  months  pregnant. 

Urine:  Trace  albumin;  specific  gravity  1030. 

Fundi  normal. 

Visual  acuity,  20/20. 

Visual  fields:  Practically  normal. 
CASE  XVI. — S.  A.,  white,  aged  twenty-five.     Nine  months  pregnant. 

Urine:  No  albumin;  specific  gravity  1022. 

Fundi  normal. 

Visual  acuity,  20/20. 

Visual  fields:  Slight  bitemporal  contraction. 

CASE  XVII. — V.  A.,  Cuban,  negress,  aged  eighteen.     Nine  months  preg- 
nant. 

Urine:  No  albumin;  specific  gravity  1005. 

Fundi  normal. 

Visual  acuity,  20/20. 

Visual  fields:  Slight  bitemporal  contraction. 


Bitemporal  Contraction  of  Visual  Fields  in  Pregnancy         151 

CASE  XVIII. — Cuban,  mulatto,  aged  thirty-one.     Nine  months  pregnant. 

Urine:  No  albumin;  specific  gravity  1030. 

Fundi  normal. 

Visual  acuity.  20  /20. 

Visual  fields:  Practically  normal. 

CASE  XIX. — C.  H.,  Cuban,  negress,  aged  twenty-eight.     Nine  months 
pregnant. 

Urine:  No  albumin;  specific  gravity  1012. 

Fundi  normal. 

Visual  acuity,  20  /20. 

Visual  fields  normal. 

CASE  XX. — G.  G.,  Cuban,  negress,  aged  thirty-one.     Nine  months  preg- 
nant. 

Urine  normal. 

Fundi  normal. 

Visual  acuity,  20/20. 

Visual  fields:  Slight  bitemporal  contraction. 

CASE  XXI. — J.   B.,   Cuban,   mulatto,  aged  thirty-nine.     Nine  months 
pregnant. 

Fundi  normal. 

Visual  acuity,  20/20. 

Visual  fields:  Moderate  bitemporal  contraction. 
CASE  XXII. — F.  I.,  Spanish,  aged  twenty-five.    Nine  months  pregnant. 

Urine:  No  albumin;  specific  gravity  1012. 

Fundi  normal. 

Visual  acuity,  20/20. 

Visual  fields:   Slight  bitemporal  contraction. 

CASE  XXIII. — C.  F.,  Cuban,  negress,  aged  sixteen.     Nine  months  preg- 
nant. 

Urine:   No  albumin;  specific  gravity  1010. 

Visual  acuity,  20/20. 

Visual  fields:  Slight  temporal  contraction  (R). 
CASE  XXIV. — P.  R.,  Spanish,  aged  thirty-six.     Eight  months  pregnant. 

Urine:  Trace  albumin;  specific  gravity  1023. 

Fundi  normal. 

Visual  acuity,  20  /20. 

Visual  fields:  Slight  temporal  contraction  (L). 

CASE  XXV. — B.  P.,  Cuban,  mulatto,  aged  eighteen.     Eight  months  preg- 
nant. 

Urine:  No  albumin;  specific  gravity  1012. 

Fundi  normal. 

Visual  acuity,  20/20. 

Visual  fields:  Slight  bitemporal  contraction. 


152  C.  E.  FlNLAY 

CASE  XXVI. — M.  0.,  Spanish,  white,  aged  twenty-two.     Eight  months 
pregnant. 

Urine:  Trace  of  albumin;  specific  gravity  1020. 

Fundi  normal. 

Visual  acuity,  20/20. 

Visual  fields:  Slight  bi temporal  contraction. 

CASE  XXVII. — A.  A.,  Spanish,  white,  aged  thirty-four.     Nine  months 
pregnant. 

Urine:  No  albumin;  specific  gravity  1020. 

Fundi  normal. 

Visual  acuity,  20/20. 

Visual  fields  normal. 

CASE  XXVIII. — V.  S.,  Cuban,  negress,  aged  twenty-two.     Nine  months 
pregnant. 

Urine:  Trace  albumin;  specific  gravity  1018. 

Fundi  normal. 

Visual  acuity,  20/20. 

Visual  fields  normal. 

CASE  XXIX. — C.  L.  V.,  Cuban,  white,  aged  seventeen.    Eight  months 
pregnant. 

Urine:  No  albumin;  specific  gravity  1025. 

Fundi  normal. 

Visual  acuity,  20/20. 

Visual  fields  practically  normal. 

CASE  XXX. — A.  P.,  Cuban  mulatto,  aged  nineteen.     Nine  months  preg- 
nant. 

Urine:  No  albumin;  specific  gravity  1016. 

Fundi  normal. 

Visual  acuity,  20/20. 

Visual  fields  normal. 
CASE  XXXI. — F.  P.,  white,  aged  twenty-eight.     Eight  months  pregnant. 

Urine:  Trace  albumin;  specific  gravity  1031. 

Fundi  normal. 

Visual  acuity,  20/20. 

Visual  fields  normal. 

From  an  examination  of  these  visual  fields  we  find  that  out  'of  the 
31  cases  examined  only  9  could  be  considered  approximately  normal, 
the  remainder  showing  changes  in  the  nature  of  a  temporal  contrac- 
tion; of  these,  8  were  slight,  9  moderate,  and  5  pronounced.  These 
surprising  results  led  me  to  a  thorough  study  of  the  literature  at 
hand  in  connection  with  the  anatomic  and  other  data  requisite  for  a 
complete  explanation.  For  a  long  time  I  was  under  the  impression 


Bitemporal  Contraction  of  Visual  Fields  in  Pregnancy         153 

that  my  observations  were  the  only  ones  made  in  this  connection, 
but  I  eventually  discovered  that  changes  in  the  visual  fields  of  a 
similar  nature  to  those  which  I  have  recorded  have  been  published 
first  by  Bellinzona  and  Tridonani,1  and  later  confirmed  by  Forti,2 
which  they  all  attributed  to  dynamic  or  vasomotor  disturbances 
similar  to  those  occurring  in  hysteria. 

This  more  or  less  forced  explanation  seems  to  me  unnecessary,  as 
the  changes  described  can  be  perfectly  explained  by  the  mechanical 
pressure  brought  to  bear  on  the  chiasm  by  the  enlarged  pituitary 
gland  resulting  from  the  normal  hypertrophy  of  this  organ  which 
occurs  in  pregnancy.  The  gland  increases  two  to  three  times  its 
weight  and  volume  during  this  state,3  this  being  due  to  an  increase  in 
number  of  oxyphil  cells  (Schwangerschaftzellen)  in  the  "pars  an- 
terior,"4 a  good  many  of  the  disturbances  occurring  in  connection 
with  pregnancy  being  probably  due  to  the  corresponding  hyper- 
function.  The  chiasm,  which  is  situated  over  the  center  of  the 
"sella  turcica,"  and  not  in  contact  with  its  anterior  border,  from  which 
it  may  be  pressed  upon  by  a  reflexion  of  the  dura  mater  (cisterna 
chiasmatis)  from  behind  and  below  by  an  enlarged  hypophysis,  if  this 
attains  at  least  a  volume  of  0.5  cm. 

The  differences  in  the  degree  of  the  changes  in  the  visual  fields  de- 
pend on  the  degree  of  hypertrophy  and  on  anatomic  peculiarities 
which  may  favor  or  hinder  the  above-mentioned  compression. 

In  conclusion  I  consider  I  can  establish:  That  during  pregnancy 
there  often  occurs,  as  a  result  of  the  normal  hypertrophy  of  the 
pituitary  gland  in  connection  with  this  state,  a  compression  of  the 
chiasm  which  manifests  itself  by  changes  in  the  visual  fields  in  the 
nature  of  a  bitemporal  contraction  which  varies  in  degree  according 
to  the  amount  of  compression  suffered,  this  depending  on  the  cor- 
responding amount  of  hypertrophy  and  on  the  anatomic  peculiarities 
of  the  case  which  may  favor  or  hinder  this  compression. 

DISCUSSION 

DR.  W.  B.  LANCASTER  (Boston,  Mass.) :  Professor  Finlay's  proposition  has 
a  great  deal  of  theoretical  interest.  In  order  to  establish  his  thesis  two  points 
have  to  be  proved:  first,  that  bitemporal  contraction  of  the  visual  field  is 
fairly  constant  in  the  normal  pregnant  woman;  second,  that  enlargement  of 

1  Bellinzona  and  Tridonani:  Boll.  d.  Soc.  med.-chir.  di  Pavia,  1903. 

2  Forti:  Arch,  di  ottal.,  February,  1910. 

3  Shafer:  Endocrine  Glands,  London,  1916,  p.  115. 

4  Erdheim  and  Stumme  and  Emory  Hill:  Amer.  Encyc.  Ophth.,  xiii,  10232. 


154  C.  E.  FlNLAY 

the  pituitary  is  also  a  fairly  constant  phenomenon  in  the  normal  pregnant 
woman.  As  to  the  latter  point,  various  men  long  ago  surmised  that  the 
pituitary  was  enlarged  in  pregnancy,  notably  Le  Conte  in  1898,  and  Launois 
and  Mulon  in  1903.  In  1908  Erdheim  and  Stumme  demonstrated  the  in- 
cidence of  this  enlargement  by  the  examination  of  150  subjects,  and  they 
showed  that  in  women  who  had  never  been  pregnant  the  average  weight  of 
the  hypophysis  was  61.8,  the  maximum,  75;  in  primiparae  the  average  was 
84.7,  the  maximum,  110;  in  multiparse  the  average  was  106,  the  maximum, 
165.  This  shows  beyond  reasonable  doubt  that  there  is  a  normal  enlargement 
of  the  pituitary  in  the  pregnant  woman. 

As  to  the  second  point,  I  happened  to  be  so  situated  as  to  have  material 
well  suited  to  add  to  the  data.  It  is  just  a  question  of  collecting  a  sufficient 
number  of  fields  from  a  sufficient  number  of  independent  sources  to  establish 
or  disprove  the  thesis.  I  was  unable  personally  to  make  these  tests,  but  I  was 
fortunate  in  enlisting  the  services  of  Dr.  Maud  Carvill,  who  is  my  associate 
on  the  staff  of  the  New  England  Hospital  for  Women  and  Children.  They 
have  a  large  obstetrical  clinic  well  suited  to  this  sort  of  test.  One  always 
wishes  that  he  could  himself  examine  the  fields  when  a  doubtful  point  comes 
up,  but  I  think  if  you  will  examine  these  charts, — and  several  hundred  have 
been  taken, — you  will  see  that  they  bear  in  themselves  the  marks  of  genuine, 
accurate,  competent  work. 

If  you,  therefore,  can  establish  the  thesis  that  the  pituitary  is  enlarged  in 
normal  cases,  and  that  the  visual  fields  are  bitemporally  contracted,  the  con- 
clusion is  irresistible  that  one  is  the  cause  of  the  other,  just  as  various  other 
phenomena  of  pregnancy  can  be  attributed  to  this  enlargement  of  the 
hypophysis,  which  is  not  always  free  from  pathologic  consequences. 

DR.  MAUD  CARVILL  (Boston,  Mass.) :  Through  the  courtesy  of  the  staff  of 
the  Maternity  Department  of  the  New  England  Hospital  for  Women  and 
Children  of  Boston  we  are  making  a  study  of  a  group  of  women  in  the  later 
weeks  of  normal  pregnancies  to  learn  to  what  extent  the  hypertrophy  of  the 
hypophysis  occurring  in  pregnancy  affects  the  visual  fields. 

Up  to  the  present  time  we  have  examined  the  visual  fields  of  sixty-seven 
gravid  women,  the  progress  of  whose  pregnancies  was  otherwise  normal,  i.  e., 
there  were  no  complications.  Their  blood  pressures,  urines  and  general  con- 
ditions were  considered  normal  by  the  internist.  Their  fundi  were  normal, 
and  their  vision  was  of  normal  acuity.  These  women  were  of  good  intelli- 
gence, many  of  them  former  students  in  our  high  schools  and  some  graduates 
therefrom.  Their  central  fixation  was  steady  and  their  peripheral  tests  very 
accurate.  The  definiteness  of  the  delineation  of  the  fields  has  impressed  us. 
In  many  cases  the  variation  of  a  degree  in  the  position  of  the  test  object  was  a 
definite  question  of  seeing  it  or  not  seeing  it.  The  fields  were  taken  by  day- 
, light  by  a  northerly  exposure,  with  a  perimeter  with  a  radius  of  28  cm.,  using 
a  5  mm.  opaque  white  test  object. 

Six  of  these  sixty-seven  cases  we  are  not  including,  as  their  last  examination 
was  taken  more  than  one  month  before  parturition  and  at  that  time  their 
fields  were  normal.  Of  the  remaining  sixty-one  cases,  only  seven,  or  11  per 
cent.,  could  be  considered  normal;  the  remaining  fifty-four  cases,  or  89  per 


Bitemporal  Contraction  of  Visual  Fields  in  Pregnancy         155 


cent.,  showed  bitemporal  contraction  of  greater  or  less  extent;  sixteen  cases, 
or  28  per  cent.,  showed  a  marked  contraction  (20°  or  more) ;  twelve  cases,  or 
20  per  cent.,  showed  moderate  contraction  (10°  to  20°);  twenty-six  cases,  or 
42  per  cent.,  showed  slight  contraction  (less  than  10°).  Five  degrees  was  the 
minimum  regarded  as  a  definite  contraction. 

The  cases  we  have  noted  in  the  literature  refer  to  the  multiparous  gravid 
state.  Professor  Finlay  has  not  stated  the  number  of  pregnancies  in  his 
cases.  About  57  per  cent,  of  our  cases  were  primiparae. 

TABLE  SHOWING  THE  VARYING  DEGREE  OF  CONTRACTION  ARRANGED  BY  GRAVID 

STATE 


Contraction 

Pregnancies 

I 

II 

III 

IV 

V 

VI 

VII 

VIII 

IX 

16-28%  marked  

11 

4 
15 
5 

1 
6 
2 
1 

'4 

2 

2 

1 

i 

2 
1 

1 

1 
1 

12-20%  moderate  

26-42%  slight              

7-11%  normal  

Total  

35 

10 

4 

4 

2 

3 

1 

2 

TABLE  SHOWING  VARYING  DEGREES  OF  CONTRACTION  OF  FIELDS  ARRANGED  BY 

AGE  OF  PATIENT 


Age 


18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

29 

30 

35-40 

40-44 

Marked  

1 

1 

3 

3 

1 

2 

1 

1 

2 

Moderate  .... 

1 

1 

5 

2 

2 

5 

3 

6 

1 

Slight      . 

1 

1 

1 

1 

1 

1 

1 

2 

1 

Normal  

1 

1 

1 

1 

1 

1 

1 

1 

1 

TABLE  SHOWING  FIELDS  IN  WEEKS  PRECEDING  PARTURITION 


Period 

Contracted 

Marked 

Moderate 

Slight 

Normal 

One  week  before  

53 

14 

17 

22 

13 

Two  weeks  before  

35 

8 

10 

17 

8    • 

Three  weeks  before  

24 

7 

8 

9 

7 

Four  weeks  before      ...    . 

15 

4 

6 

5 

6 

Five  weeks  before 

10 

2 

5 

3 

5 

Six  or  more  weeks  before.  .  .  . 

4 

1 

2 

1 

3 

156  C.  E.  FlNLAY 

The  conclusive  studies  of  Erdheim  and  Stumme  prove  the  question  of  func- 
tional hypertrophy  beyond  the  stage  of  conjecture.  These  authors  have 
demonstrated  by  actual  measurement  an  increase  in  size  and  weight  of  the 
structure  of  the  pituitary  gland.  After  parturition  there  occurs  a  subsidence, 
the  involution  being  complete  at  the  termination  of  lactation.  With  a  suc- 
ceeding pregnancy  a  further  augmentation  takes  place.  Bandler  states  in  his 
book  on  "Endocrinology,"  published  in  1921,  that  "the  gland  never  goes 
back  to  its  former  ante-pregnant  stage." 

In  the  42  cases  which  we  have  examined  postpartum,  all  but  four  have  had 
normal  fields.  We  think  later  examinations  would  have  found  these  normal. 

PROFESSOR  F.  DE  LAPERSONNE  (Paris,  France) :  J'ai  e'te'  extremement  in- 
teresse"  par  la  communication  de  M.  le  Professeur  Finlay.  Si  ses  recherches 
sont  confirmees  dans  un  tres  grand  nombre  de  cas,  c'est  un  nouveau  chapitre 
qui  s'ouvre  pour  la  physiologic  pathologique  de  1'hypophyse.  Dans  les  champs 
visuels  qui  nous  sont  pre"sentes,  tous  n'ont  pas  les  dispositions  caracteristiques 
de  rhe"mianopsie  bitemporale. 

A  cote"  de  ces  troubles  passagers,  disparaissant  apres  la  grossesse,  il  en  est 
peut-etre  qui  persistent.  J'ai  observe"  une  dame  de  35  ans  qui,  au  cours  de  sa 
troisieme  grossesse,  eut  des  ce'phale'es,  de  la  polyurie,  sans  glycosurie,  et  dif- 
ferents  troubles  endocriniens.  L'ayant  examinee  huit  mois  apres  la  grossesse, 
je  constatai  une  hemianopsie  bitemporale  avec  atrophie  partielle  de  la  papille; 
1'autre  oeil  etait  atrophi^  depuis  longtemps.  Le  Wassermann  e"tait  ne"gatif  et 
la  selle  turcique  16gerement  augmente'e.  Si  la  grossesse  n'a  pas  (He"  la  cause 
primaire  de  cette  Idsion  hypophysaire,  elle  paratt  1'avoir  nettement  aggrav6e. 

PROFESSOR  C.  E.  FINLAY  (closing) :  In  regard  to  Dr.  Lancaster,  I  am  glad 
he  is  able  to  confirm  both  the  enlargement  of  the  gland,  as  well  as  the  bi- 
temporal  contraction.  I  am  interested  in  seeing  the  cases  of  Dr.  Carvill  and 
how  the  visual  fields  compare  with  mine,  especially  as  Dr.  Lancaster  men- 
tions that  some  of  these  cases  are  quite  typical  in  their  characteristics.  Owing 
to  the  length  of  time  of  pregnancy  the  bony  body  where  the  hypophysis  lies 
is  hardly  formed,  and  one  would  not  expect  it  except  where  there  is  some  com- 
pression against  a  bony  wall. 

I  have  had  a  similar  case  to  that  mentioned  by  Professor  de  Lapersonne  of 
the  appearance  of  these  symptoms  after  pregnancy.  Most  of  the  cases  which 
I  followed  afterward  showed  that  the  bitemporal  contraction  disappeared 
comparatively  rapidly  after  pregnancy,  but  lately  I  saw  a  woman  who,  two 
years  after  pregnancy,  was  suffering  from  headaches  and  blurring  of  vision, 
and  in  whom  I  found  a  slight  optic  neuritis  and  a  bitemporal  contraction.  I 
cannot  state  whether  this  was  the  hypertrophy  of  pregnancy  which  had  not 
disappeared,  or  whether  the  pregnancy  provoked  this  in  a  patient  already  pre- 
disposed, or  whether  it  was  simply  an  independent  hypophyseal  tumor.  But 
examination  showed  a  marked  enlargement  of  the  sella  turcica. 


LES  ECHANGES  D'EAU  ET  D'lONS  A 
TRAVERS  LA  CORNEE 

DR.  V.  MORAX 

Paris,  France 

La  question  des  echanges  a  travers  la  cornee  est  une  de  celle  qui 
doit  interesser  le  plus  Pophtalmologiste  puisque  la  part  la  plus  im- 
portante  de  sa  therapeutique  locale  repose  sur  les  phenomenes  d'ab- 
sorption  et  d'absorption  qui  se  produisent  a  travers  la  coque  oculaire. 
Lorsque  par  une  instillation  d'atrophine  ou  de  pilocarpine,  nous  pro- 
voquons  la  dilatation  ou  le  retrecissement  de  la  pupille,  nous  faisons 
passer  dans  la  chambre  anterieure  une  certaine  quantite  de  substance 
active,  celle-ci  etant  a  son  tour  absorbee  par  le  tissu  irien. 

Si  cet  effet  physiologique  du  passage  des  substances  medicamen- 
teuses  est  bien  connu,  le  mecanisme  de  sa  production  est  par  centre 
tres  ignore.  Ce  n'est  certes  pas  que  la  question  n'ait  pas  ete  etudiee 
de  divers  cotes  mais  elle  1'a  ete  surtout  jusqu'ici  au  point  de  vue  pure- 
ment  chimique.  Or;  1'analyse  chimico-physique  a  transforme  1'etude 
des  echanges  a  travers  les  membranes. 

De  nouvelles  conceptions  sur  la  tension  osmotiques  des  solutions, 
sur  la  constitution  ionique,  des  sels  se  sont  developpees  et  il  nous  a 
paru  necessaire  d'aborder  la  question  des  echanges  a  travers  la  cornee 
a  la  faveur  de  tous  les  progres  realises  dans  1'etude  des  phenomenes 
chimico-physiques.  Les  recherches  dont  je  voudrais  donner  ici  un 
court  resume  ont  etc"  faites  en  collaboration  avec  M.  Girard  ou  avec 
M.  Girard  et  Mestrezat.  Bien  qu'elles  soient  encore  loin  d'etre 
achevees,  certains  re'sultats  peuvent  des  maintenant  interesser  Pocu- 
liste  et  le  physiologiste. 

II  s'attache  en  effet  un  grand  interet  pratique  a  1'etude  des  moyens 
qui  permettent  de  modifier  le  "milieu  interieur  de  1'ceil  qui  est  1'hu- 
meur  aqueuse.  Ces  modifications  peuvent  etre  envisagees  a  deux 
points  de  vue;  au  point  de  vue  du  volume  liquide  dont  depend  un 
facteur  physiologique  essentiel  qui  est  la  tension  oculaire  et  au  point 
de  la  constitution  chimique  et  notamment  de  la  constitution  ionique 
de  1'humeur  aqueuse.  Ce  dernier  probleme  qui  touche  egalement  a 

157 


158  V.  MORAX 

la  therapeutique,  est  en  somme  celui  de  la  permeabilite  de  la  cornee 
aux  substances  dissoutes  dans  les  solutions  qui  en  baignent  Pepi- 
thelium  externe. 

Nos  recherches  ont  d'abord  trait  a  un  moyen  pratique  nouveau  de 
faire  yarier  le  volume  de  1'humeur  aqueuse  dans  la  chambre  anteri- 
eure  et  de  modifier  par  consequent  la  tension  oculaire  en  elevant  ou 
en  abaissant  considerablement  la  valeur.  Ce  moyen,  c'est  1'osmose 
electrique  (endosmose  ou  exosmose) .  Nous  ne  voulons  pas  developper 
ici  la  theorie  du  phenomene  et  la  representation  qu'on  peut  se  faire 
de  son  mecanisme ;  nous  ne  1'encisagerons  que  comme  moyen  pratique. 
Disons  d'abord  que  ces  osmoses  electriques,  nous  les  avons  pratiques 
sur  1'ceil  vivant  et  en  place  de  1'animal  vivant.  Essentiellement, 
elles  consistent  dans  le  glissement  sous  1'action  d'un  champ  elec- 
trique, de  veines  liquides  dans  les  interstices  cellulaires  d'un  tissu 
vivant, — la  cornee  en  1'espece.  L'un  des  poles  de  la  sourcee  electrique 
qu'on  utilise,  etant  relie  a  un  point  quelconque  du  corps  de  1'animal 
par  une  large  electrode,  une  electrode  en  platine  reliee  a  Fautre  pole 
plonge  dans  la  solution  d'electrolyte  dont  est  baigrie  'par  le  moyen 
d'un  bain  d'ceil  en  verre  1'epithelium  externe  de  la  cornee.  La 
theorie  du  phenomene  fait  prevoir  que  pour  une  valeur  et  une 
orientation  fixees  du  champ — difference  de  potentiel  entre  la  cornee 
et  la  solution  qui  en  baigne  1'epithelium  externe — ce  sera  de  la  consti- 
tution ionique  de  cette  solution  que  dependra  le  sens  du  glissement 
des  veines  liquides  dans  les  interstices  cellulaires:  endosmose  ou 
exosmose. 

Pour  une  connection  polaire  telle  que  la  cathode  etant  au  corps  de 
1'animal  1'anode  plonge  dans  le  liquide  du  bain  d'ceil,  on  obtient 
lorsque  celui-ci  est  constitue  par  des  solutions  de  sulfate  de  magnetic 
des  endosmoses  qui  font  monter  la  tension  intraoculaire,  au  bout  de 
30  minutes  environ  de  25  a  70  ou  50  millimetres  de  Hg.  Au  con- 
traire,  toujours  pour  la  meme  connection  polaire,  lorsque  ce  liquide 
est  constitue"  par  une  solution  de  nitrate  de  calcium,  cette  tension 
oculaire  s'abaisse  dans  le  meme  temps  du  fait  de  1'exosmose  de  1'hu- 
meur  aqueuse  qui  filtre  a  travers  la  cornee  hors  de  1'organisme  a  8  ou  10 
millimetres  de  Hg. 

A  la  fin  de  1'experience,  lorsque  les  precautions  necessaires  ont  ete 
prises  (concentrations  moleculaires  convenable  de  la  solution,  debit 
electrique  ne  depassant  pas  2  milliamperes  et  surtout  absence  d'elec- 
trolyse),  on  ne  constate  aucune  lesion  de  la  cornee,  non  plus  qu'aucune 
trace  d'oedeme. 


Les  Echanges  d'Eau  et  d'lons  a  Travers  la  Cornee  159 

Ajoutons  que  sur  les  yeux  dont  la  circulation  est  normale  et  sur 
lesquels  aucun  blocage  vasculaire  n'a  dte  pratique,  ces  desequilibres 
de  tension  se  re"parent  au  bout  d'une  heure  environ  et  I'humeur 
aqueuse  dite  de  nouvelle  formation  differe  alors  de  1'humeur  aqueuse 
normale. 

Mais  ce  n'est  pas  seulement  le  volume  de  1'HA.,  c'est  aussi  la  con- 
stitution ionique  qu'il  est  possible  de  modifier  momentanement  tout 
au  moins. 

L'utilisation  d'un  champ  electrique  pourra  etre,  en  vue  de  cette  fin 
tres  avantageuse;  mais  elle  n'est  pas  indispensable  et  au  cours  de  nos 
experiences  sur  les  echanges  d'ions  a  travers  la  cornee,  nous  avons 
utilise  tres  souvent  la  diffusion  pure  et  simple  sans  source  electrique 
exterieure. 

Le  fait  essentiel  que  nous  avons  trouve — en  collaboration  pour  cette 
partie  avec  M.  Mestrezat — peut  se  resumer  ainsi:  lorsqu'une  solution 
d'un  sel  determine,  dissocie  en  ses  ions,  baigne  la  cornee  dans  1'HA., 
ce  n'est  pas  le  sel  qui  diffuse  a  travers  le  cornee  dans  I'humeur  aqueuse, 
ou  plus  exactement  les  deux  ions  de  ce  sel,  ainsi  dissocie  ne  diffusent 
jamais  en  proportions  chimiquement  equivalentes.  Si,  par  exemple, 
la  solution  est  constitute  par  du  sulfate  de  magnesie,  il  ne  diffusera  pas 
dans  1'humeur  aqueuse,  un  nombre  egal  d'anions  et  de  cations  (comme 
cela  se  passerait  si  c'etait  du  sulfate  de  magnesie  qui  diffusait  dans  la 
chambre  anterieure,  mais  il  diffusera  beaucoup  plus  d'ions  magnesium 
que  d'ions  sulfate  en  sorte  que  ce  ne  sera  plus  du  sulfate  de  magnesie 
qui  aura  diffuse  dans  1'hiimeur  aqueuse.  Mais  d'autre  part,  comme 
1'exces  de  magnesium  a  diffuse  sous  forme  d'ions  porteurs  de  charges 
electriques  positives,  et  que  I'humeur  aqueuse  reste  cependant  electri- 
quement  neutre — aucune  charge  non  compensee  n'y  apparassant  le 
principe  de  Pequilibre  electrique  exige  qu'au  passage  dans  un  sens 
d'un  exces  d'ions,  corresponde  le  passage  en  sens  inverse — c'est  a 
dire  vers  la  solution  baignant  1'ceil — d'un  nomber  electriquement  et 
chimiquement  equivalent  d'ions  (metalliques)  de  meme  signe.  Ce 
serait,  par  exemple,  les  ions  sodium  de  1'humeur  aqueuse. 

Ensorte  que  le  contact  de  1'epithelium  externe  de  la  cornee  avec 
une  solution  de  sulfate  de  magnesie — nous  prenons  ce  sel  a  titre 
d'exemple — n'a  pas  du  tout,  comme  consequence  comme  il  eut  e"te 
naturel  de  le  penser,  1'enrichissement  de  I'humeur  aqueuse  en  sulfate 
de  magnesie;  I'humeur  aqueuse  s'enrichit  relativement  beaucoup  en 
magnesium,  tres  peu  en  ions  SCX — Pour  certains  sels,  comme  les  sels 
d'ammonium,  la  discrimination  est  tellement  accusee  que  pratique- 


160  CHARLES  F.  HARFORD 

ment  un  seul  ion  passe — et  elle  s'apauvrit  en  un  metal  qui  sera  par 
exemple  du  sodium  en  une  proportion  electriquement  et  chimique- 
ment  equivalente  a  celle  en  laquelle  elle  s'est  enrichie  en  magne'sie. 
II  en  re"sulte  dans  la  composition  ionique  de  1'humeur  aqueuse  de  tres 
importantes  modifications. 

Pour  certains  sels  comme  les  sels  monocalents  d'ammonium  ce  sont 
au  contraire  les  anions  (radicaux  acides)  qui  diffusent  en  exces,  exces 
si  grand  parfois  qu'on  peut  ici  parler  d'une  veritable  hemipermeabilite 
ionique.  D'ailleurs  il  est  possible  en  faisant  varier  la  reaction  du 
milieu  (legere  alcalinite  ou  le"gere  acidite")  de  modifier  ou  meme 
d'inverser  le  sens  de  ces  r6sultats. 

La  re'elle  difficulte  dans  ces  experiences  a  e"te  de  pratiquer  sur  des 
quantites  tres  petites  (chaque  ponction  d'humeur  aqueuse  ne  donnant 
guere  que  2  a  3/10  de  cent.)  le  dosage  des  2  ions  de  chaque  sels.  Seules 
les  niethodes  microchimiques  permirent  de  la  surmonter.  De  1'en- 
quete  syste"matique  que  nous  comptons  poursuivre  relativement  a 
cette  perme'abilite  elective  de  la  cornee  vis  a  vis  lesions,  sortiront  peut- 
etre  d'interessantes  conclusions  chimio-therapeutique. 


PSYCHOPATHOLOGY  IN  OPHTHALMIC  PRACTICE 

CHARLES  F.  HARFORD,  M.A.,  M.D. 
Cambridge,  M.R.C.S.  Eng.,  L.R.C.P.  London 

Ophthalmology  occupies,  in  many  ways,  a  central  position  among 
the  various  departments  of  medical  and  surgical  practice.  This  was 
well  shown  in  a  paper  by  Dr.  F.  Park  Lewis  at  the  meeting  of  the 
American  Medical  Association  at  Atlantic  City,  N.  J.,  in  June,  1919. 
The  author  took  as  an  illustration  the  close  connection  between  den- 
tal caries  and  many  forms  of  ophthalmic  disease.  He  might  have 
greatly  extended  the  scope  of  his  paper  and  traced  the  intimate  con- 
nection of  ophthalmology  with  all  the  general  infections,  especially 
those  which  are  of  a  chronic  character. 

There  is,  however,  a  new  field  of  medical  research  which  is  rightly 
claiming  close  attention  at  the  present  time  which  is  destined  to  in- 
fluence every  branch  of  medical  study,  and  that  is  the  rapidly  de- 
veloping science  of  psychopathology.  No  department  is  more  likely 
to  be  affected  by  this  than  that  of  ophthalmology.  It  is  not  only 
that  ophthalmic  conditions  often  form  an  exciting  factor  in  the  on- 
set of  the  psychoneuroses,  but  that  there  are  psychic  elements  com- 


Psychopathology  in  Ophthalmic  Practice  161 

plicating  most  ophthalmic  diseases.  Thus  again  we  find  the  central 
place  of  ophthalmology  and  the  necessity  of  recognizing  the  psycho- 
logic aspects  of  ophthalmic  work,  and,  where  necessary  >  of  full  cooper- 
ation with  those  who  practise  psychotherapy. 

I  have  been  led  to  realize  the  urgency  of  this  problem  by  certain  cir- 
cumstances which  it  may  be  of  some  interest  to  record.  During  the 
war,  when  acting  as  an  ophthalmologist  in  connection  with  a  British 
division  composed  very  largely  of  miners,  I  was  for  the  first  time 
brought  in  contact  with  the  ailment  most  unfortunately  named 
miners '  nystagmus.  Recognizing  the  seriousness  of  the  malady,  and 
believing  that  it  would  be  of  some  value  to  record  observations  on 
these  cases  when  removed  from  underground  work,  I  prepared  a  paper 
on  this  subject.  The  paper  was  published  in  the  British  Medical 
Journal  on  March  4,  1916,  with  the  title,  "Visual  Neuroses  of  Miners 
in  Their  Relation  to  Military  Service."  I  pointed  out  that  nystag- 
mus was  only  one  of  a  series  of  symptoms  in  the  disease,  and  drew  at- 
tention to  the  great  importance  of  the  mental  factor  and  the  possibil- 
ity that  these  cases  might  be  treated  by  suggestion.  At  that  time  I 
was  not  interested  in  psychology  as  I  have  been  during  the  past  two 
years,  but  the  study  of  these  cases  gave  me  a  special  interest  in  the  re- 
lation between  the  mind  and  vision. 

At  the  Ophthalmological  Congress  in  London  in  May,  1921,  I  took 
part  in  a  discussion  on  the  Psychology  of  Vision  in  Health  and  Dis- 
ease, and  expressed  in  that  my  strong  conviction  as  to  the  importance 
of  knowledge  of  modern  psychologic  teaching  in  ophthalmic  work. 
I  had  for  the  previous  eighteen  months  been  engaged  in  special  study 
on  these  lines,  with  the  result  that  I  had  benefited  in  my  own  powers 
of  work  and  found  great  scope  for  the  exercise  of  the  knowledge  gained 
in  my  own  practice. 

After  six  months '  further  study  I  decided  to  formulate  more  clearly 
the  conceptions  which  had  helped  me,  and  on  November  11,  1921,  I 
contributed  a  paper  to  the  Ophthalmological  Section  of  the  Royal 
Society  of  Medicine  of  London  on  "The  New  Psychology  in  its  Rela- 
tion to  Problems  of  Vision. "  This  has  been  published  in  the  Medical 
Press  and  Circular  on  November  30  and  December  7,  1921.  The  pres- 
ent paper  is  intended  to  be  a  sequel,  and  it  will  be  necessary  to  refer 
very  briefly  to  the  line  adopted  in  that  contribution,  seeing  that  a 
proper  appreciation  of  the  general  lines  of  normal  psychology  is  essen- 
tial before  proceeding  to  deal  with  psychopathology.  This  is  the  more 
necessary  in  view  of  the  great  diversity  of  opinion  which  prevails  on 
11 


162 


CHARLES  F.  HARFORD 


these  subjects.  A  chart  was  used  to  represent  the  working  of  the 
psyche,  and  this  is  reproduced  here  in  order  to  make  clear  the  stand- 
point of  the  author.  The  chart  includes  the  following  parts: 

1.  A  circle  X  representing,  as  if  it  were  a  gramophone,  the  mechan- 
ism of  the  psyche  divided  into  its  three  sections  of  a  cognition,  by 
which  an  image  or  impression,  visual  or  otherwise,  is  recognized;  an 


CHART  OF  ACTION  OF  PSYCHE 


ve 


RESULTS  OF  CASUAL 
OBSERVATION 


THE  AMNESIA  OF 
COMMON    LIFE 


PATHOLOGICAL  REPRESSION 


INSTINCTIVE  AND  HEREDITARY 


INFANTILE 


STORE -CHAMBERS    OF    PSYCHE    BELOW  CENTRAL 
LINE   =     THE    UNCONSCIOUS 


affection,  which  stands  for  the  emotional  result  of  cognition,  which  in 
its  turn  leads  to  a  conation  or  action. 

2.  A  second  disc,  Y,  as  if  it  were  a  gramophone  record,  stood  for  the 
field  of  consciousness,  which  would  present  to  the  psyche  the  visual 
and  other  images  or  impressions  received  from  external  objects  or  from 
the  memory  or  from  both  combined. 


Psychopathology  in  Ophthalmic  Practice  163 

3.  The  store-chambers  of  the  psyche  or  of  the  memory  were  de- 
scribed as  divided  into  six  compartments,  referred  to  as — (a)  results  of 
careful  observation ;  (6)  results  of  casual  observation ;  (c)  amnesia  of 
common  life;  (d)  pathologic  repression;  (e)  infantile  impressions; 
(/)  instinctive  and  hereditary  factors.  These  signified  the  author's 
idea  of  what  is  usually  termed  the  unconscious,  and  the  circles  within 
them  indicated  the  mental  concepts  stored  in  the  memory  which  were 
spoken  of  as  psychograms. 

The  salient  features  in  this  scheme  may  be  explained  as  follows: 

1 .  The  part  of  the  circle  X  marked  with  shading  or  black  was  taken 
to  represent  the  emotional  part  of  the  psyche,  which  was  also  regarded 
as  the  center  of  force  or  energy  in  the  working  of  the  mind.     This,  in 
the  author's  view,  was  comparable  to  the  "elan  vital"  of  Bergson,  the 
"  libido  "  of  Freud  or  Jung,  or  "  the  urge  "  of  English-speaking  psychol- 
ogists, whatever  their  special  conception  might  be  as  to  the  nature  of 
this  all-pervading  force. 

The  marking  in  a  similar  manner  of  the  psychograms  stored  up  in 
the  unconscious  indicated  that  each  mental  concept  is  activated  by 
this  emotional  force,  with  its  conflicting  character.  This  might  be 
illustrated  by  ideas  of  attraction  or  repulsion,  of  light  or  darkness,  of 
harmony  or  discord,  of  rest  or  pain,  of  hope  or  fear,  or  any  other  antag- 
onistic forces.  This  is  laid  stress  upon  seeing  that  the  conflict  graphic- 
ally described  by  Freud,  which  is  an  essential  element  in  psycho-an- 
alysis, may  be  regarded  as  a  prominent  symptom  in  all  kinds  of  dis- 
ease. Some  aspect  of  distress  is  a  constant  factor  in  every  ailment, 
whether  it  is  a  malignant  tumor,  toothache,  or  an  error  of  refraction, 
and  it  is  this  which  we,  whose  duty  it  is  to  combat  human  ills,  are  called 
upon  to  alleviate. 

2.  The  second  point  of  importance  to  which  attention  is  directed  is 
to  the  medium,  as  shown  by  the  disc  Y,  whereby  diverse  impressions 
or  images,  whether  of  the  past  or  present,  are  harmonized  and  pre- 
sented to  the  main  mechanism  of  the  psyche. 

It  was  this  harmonizing  or  reconciliation  between  new  images  and 
past  memories,  or  in  psychologic  terms  of  apperception,  which  was  the 
main  point  of  the  paper  which  demonstrated,  by  various  instances, 
that  visual  memory  is  an  essential  feature  in  every  visual  concept. 
The  instances  given  were  the  following:  infantile  vision;  individuals 
blind  from  birth;  the  recognition  of  strange  objects;  the  use  of  optical 
apparatus;  the  artistic  eye;  the  athletic  eye. 

The  meaning  of  the  disc  Y  was  also  regarded  as  an  illustration  of 


164  CHARLES  F.  HARFORD 

even  wider  significance.  Though  it  is  marked  in  the  chart  with  the 
words  " field  of  consciousness,"  yet  it  is  suggested  that  there  may  be 
modifications  of  this  idea  which  might  represent  the  dream  state  or 
the  hypnotic  state,  and  might  be  labeled  Yl  or  Y2.  Thus,  on  falling 
to  sleep  the  change  from  Yl  to  Y2  would  occur,  this  dream  state  being 
one  in  which  access  appears  to  be  attained  to  chambers  of  the  psyche 
which  are  inaccessible  to  the  normal  conscious  state.  These  different 
states  are  instances  of  the  process  of  dissociation  which  is  responsible 
for  most  of  the  abnormalities  of  mental  life,  and  is  represented  by  cases 
of  so-called  multiple  personality,  forms  of  drug  intoxication,  or  actual 
insanity. 

This  may  also  explain  the  visual  irregularity  spoken  of  as  "  deja  vu," 
or  false  recognition,  which  has  been  the  subject  of  many  hypotheses. 
Bergson  has  devoted  much  attention  to  it,  and  it  has  been  dealt  with 
recently  by  Kinnier  Wilson  at  the  last  Ophthalmological  Congress  in 
London  in  1921,  when  he  gave  instances  of  this  phenomenon  in  relation 
to  epilepsy.  Of  these  epileptic  cases  I  have  no  personal  knowledge, 
but  I  have  recently  conversed  with  a  number  of  people  who  claim  to 
have  had  this  experience  in  ordinary  life.  In  these  cases  I  am  strongly 
of  opinion  that  the  condition  is  due  to  a  momentary  day  dream.  Let 
me  give  an  illustration  of  this. 

A  soldier  in  the  recent  war  came  to  the  top  of  Cassel  Hill  in  France, 
near  to  the  Flanders  frontier.  When  he  saw  the  view  of  the  plain 
stretched  before  him  he  at  once  felt  that  he  had  been  there  before,  and 
had  seen  precisely  the  same  picture,  though  he  knew  that  this  was 
impossible.  A  similar  story  is  told  by  others,  most  of  whom  would  re- 
ject with  scorn  the  idea  that  they  were  remembering  a  similar  situa- 
tion or  had  only  seen  a  picture  of  the  view.  They  are  certain  that  the 
picture  is  identical.  This  I  believe  is  due  to  a  day-dream.  For  the 
moment  when  they  are  brought  face  to  face  with  the  new  condition, 
some  alternative  Y  disc  must  be  in  operation  which  receives  the  im- 
pression and  is  immediately  replaced  by  the  normal  conscious  disc, 
and  the  whole  impression  has  thereupon  been  relegated  to  the  store- 
chambers  of  the  memory  without  appreciation  of  space  or  time.  This 
is  the  explanation  which  satisfies  me  and  has  satisfied  those  with  whom 
I  have  spoken  who  have  themselves  experienced  the  phenomenon 
which  is  infinitely  more  important. 

3.  The  third  essential  feature  of  the  chart,  the  store-chambers  of 
the  memory,  represents  not  only  the  accumulation  of  ideas,  but  the 
storehouse  of  energy.  Starting  from  instinctive  and  hereditary  be- 


Psychopathology  in  Ophthalmic  Practice  165 

ginnings  with  the  psychic  momentum,  which  has  been  acquired 
throughout  life,  it  forms  the  wonderful  conception  of  the  mind  which 
is  being  unfolded  to  us  in  what  may  be  called  the  story  of  the  un- 
conscious. Here  is  the  inexhaustible  mine  from  which  we  may  ob- 
tain the  solution  of  many  of  life's  riddles;  this  is  the  great  dynamic 
force  which  is  elusive  to  the  impetuous  promptings  of  the  will,  but  can 
be  influenced  by  suggestion  or  auto-suggestion ;  yet  all  of  these  are 
under  the  control  directly  or  indirectly  of  the  personality  of  the 
normal  man,  and  for  them  he  is  responsible. 

Thus  we  have  endeavored  to  picture  the  working  of  the  human 
mind,  not  as  an  isolated  problem,  but  in  its  relation  to  vision.  No  at- 
tempt has  been  made  to  correlate  in  any  exact  manner  the  functions  of 
the  psyche  and  the  soma,  or  yet  the  higher  realms  of  the  pneuma,  but 
it  is  the  author 's  firm  belief  that  each  of  the  domains  of  spirit  soul  and 
body  must  be  explored  in  their  relation  to  one  another.  Only  thus 
can  we  satisfactorily  treat  the  whole  man — the  patient  who  seeks  our 
aid. 

For  the  moment  it  is  the  psyche  and  soma  which  are  under  special 
consideration  because  of  the  new  light  which  is  being  thrown  upon  the 
working  of  the  psyche.  So  far  as  these  are  concerned  we  must  regard 
the  psyche  as  the  directing  force,  and  as  the  nearest  approach  to  the 
essential  ego  that  we  have  yet  reached.  This  then  is  the  new  stand- 
point from  which  we  must  view  our  ophthalmic  practice.  We  must 
be  no  less  scrupulous  in  our  methods  of  examining  organic  defects,  or 
in  the  identification  of  cerebral  or  nervous  lesions,  but  above  all  we 
must  include  in  our  reckoning  the  psychologic  factor. 

The  application  of  the  new  psychology  to  ophthalmic  practice  will 
only  gradually  be  realized,  but  it  is  hoped  that  the  suggestions  which 
have  been  made  as  to  the  methods  of  mind-working  may  help  many 
to  interpret  some  of  the  difficulties  occurring  in  their  own  practice. 

We  will  now  endeavor  to  describe  some  of  the  cases  in  which  psycho- 
pathology  and  ophthalmology  meet.  Most  of  these  will  include  some 
measure  of  dissociation  in  which  repression  with  amnesia  will  have  a 
part,  and  in  which  often,  in  proportion  to  the  amnesia,  there  will  be 
some  emotional  distress.  In  all  of  these  it  is  probable  that  an  un- 
conscious motive  can  be  detected,  and  the  demonstration  of  this  may 
lead  to  the  resolving  of  the  conflict,  the  restoration  of  harmony,  and 
relief  from  the  distress. 

We  shall  proceed  to  consider  these  cases  in  three  main  classes: 


166  CHARLES  F.  HARFORD 

I.    THE  PSYCHOPATHOLOGY  OF  EvERY-DAY  LlFE 

This  admirable  phrase,  used  by  Freud  as  the  title  of  a  volume,  will 
form  a  good  introduction  to  our  subject.  It  is  a  mistake  to  regard  all 
psychic  disturbances  as  conditions  which  can  be  dealt  with  only  by 
specialists  in  psychotherapy.  The  truth  is  that  there  is  a  psychic  ele- 
ment in  every  malady,  and  that  whether  we  know  it  or  not  we  must 
deal  with  it  if  we  are  to  help  our  patients.  Every  practical  physician 
or  surgeon  recognizes  this,  though  perhaps  unconsciously,  and  an 
older  generation  with  its  stress  on  temperament,  anticipated  much 
that  is  being  taught  in  a  new  way  to-day.  The  manner  of  the  older 
practitioner  was  studied  more  closely  perhaps  than  at  the  present 
time,  and  the  confident  assurance  of  success  in  treatment  can  be  re- 
garded only  as  a  method  of  suggestion.  To-day  we  approach  these 
problems  with  new  light.  In  our  ophthalmic  clinics  public  or  private 
patients  come  to  us  not  so  much  because  they  know  of  any  distinct  dis- 
ability, but  because  they  are  anxious  about  themselves. 

Mysterious  pains  in  the  eye  or  head,  floating  bodies  or  clouds  before 
the  eyes,  unusual  appearances  about  the  eyes  or  lids,  are  often  re- 
garded as  threatening  disaster,  perhaps  blindness.  In  many  cases 
the  anticipation  of  evil  is  more  serious  than  any  actual  disease,  and 
may  even  produce  illness,  and  in  some  this  foreboding  is  the  only 
trouble  with  which  we  may  have  to  deal. 

Obviously,  our  duty  is  to  eliminate  any  organic  disease  or  cause  for 
trouble,  including  particularly  the  correction  of  refractive  errors. 
We  must  further  seek  to  convince  our  patient  by  our  methods  and 
manner  that  we  are  genuinely  concerned  in  delivering  him  from  his 
fears,  whether  real  or,  as  we  may  style  them,  imaginary.  Only  thus 
can  we  obtain  that  true  "rapport"  which  must  exist  between  doctor 
and  patient  if  success  is  to  be  insured.  This  gained,  we  may,  by 
simple  persuasion,  be  able  to  clear  away  the  fear  and  suffering  which 
may  still  exist,  not  because  the  patient  is  intentionally  exaggerating 
his  symptoms,  but  because  of  some  unconscious  prejudice  or  habit 
which  is  responsible  for  the  trouble.  It  is  useless  to  treat  these  cases 
by  stern  rebukes  or  ridicule,  however  veiled.  Action  of  this  kind  will 
only  develop  resistances  which  may  result  in  troublesome  repression 
with  an  intensification  of  the  malady. 

Freud  points  out  that  the  ordinary  forgetfulness  of  every-day  life, 
the  slips  of  tongue  and  pen  and  other  trivial  blunders,  are  frequently 
due  to  an  unconscious  cause  which  may  be  discovered. 

Let  us  take  an  example  from  the  common  experience  of  a  refraction- 


Psychopathology  in  Ophthalmic  Practice  167 

ist.  The  prejudice  against  glasses  is  often  very  great.  In  the  poorer 
districts  of  London,  and  no  doubt  elsewhere,  those  who  wear  glasses 
are  called  goggle-eyed  or  some  similar  nickname  is  given  to  them. 

During  the  war  soldiers  were  greatly  prejudiced  against  glasses,  be- 
cause the  army  glasses  were  round  instead  of  oval,  as  is  most  commonly 
supplied  in  England. 

Many  girls  prefer  to  endure  any  amount  of  suffering  rather  than 
wear  any  form  of  glasses  which  may  not  be  regarded  as  becoming. 

The  result  of  this  is  the  development  of  an  unconscious  motive, 
which  shows  itself  in  an  unwillingness  to  give  a  correct  history,  in 
mistakes  in  reading  test  types,  and  later  on  in  difficulty  with  the 
glasses.  These  patients  have  come  to  us  for  some  real  complaint 
and  a  desire  for  relief  from  their  troubles,  but  when  they  are  brought 
face  to  face  with  the  remedy,  they  shirk  the  issue.  They  may  be 
said  to  regress,  to  prefer  phantasy  to  reality — in  a  word,  they  act  like 
children. 

Any  one  with  observation  on  these  lines  could  multiply  instances  in- 
definitely where  similar  prejudices  complicate  our  practice. 

II.  PSYCHIC  DISORDERS  OF  A  MORE  PRONOUNCED  FORM  ASSOCIATED 
WITH  VISUAL  DISTURBANCES 

We  now  come  to  a  second  class  of  cases  of  a  definite  psychopathic 
character,  which  may  vary  from  the  persistent  headache  to  the  more 
pronounced  forms  of  psychic  troubles.  The  nomenclature  of  these 
conditions,  which  includes  such  terms  as  hysteria  and  neurasthenia, 
is  liable  to  be  misleading,  so  we  will  not  here  attempt  any  definite 
classification. 

It  will  be  sufficient  to  mention  some  of  the  symptoms  common  to 
many  of  these  conditions.  Headache,  minor  obsessions  or  delusions, 
often  visual,  tremors  of  various  kinds,  disorders  of  the  circulatory, 
respiratory,  or  the  many  glandular  systems  of  the  body,  may  all  be 
met  with.  Fatigue,  inability  to  concentrate  on  mental  work,  varieties 
of  amnesia,  insomnia,  and  phobias  of  a  distressing  type  may  all  occur. 

Ophthalmologists  have  for  long  been  aware  of  the  importance  of 
correcting  errors  of  refraction  in  cases  of  this  kind,  but  with  new 
knowledge  much  better  results  may  be  anticipated.  These  are  un- 
doubtedly cases  which  call  for  comprehensive  treatment,  and  should 
be  dealt  with  by  a  psychotherapist,  but  many  of  them  will  first  consult 
an  ophthalmologist,  owing  to  the  prominence  of  symptoms  referable 
to  the  eye  and  the  importance  of  being  able  to  diagnose  the  condition 
is  evident. 


168  CHARLES  F.  HARFORD 

To  take  an  instance  from  my  own  practice: 

A  patient  consulted  me  on  account  of  symptoms  which  had  shown 
themselves  a  few  weeks  previously  on  the  occasion  of  the  last  eclipse  of 
the  sun.  He  had  looked  at  the  sun  without  proper  safeguards,  and  he 
believed  that  his  eyes  had  been  injured  thereby. 

He  had  some  conjunctivitis  and  some  slight  astigmatism,  and  both 
of  these  conditions  were  dealt  with.  There  was  no  sign  of  any  retinal 
lesion  and  no  scotoma  or  interference  with  his  color  perception.  It 
seemed  clear  that  his  main  trouble  was  psychic,  and  this  was  confirmed 
later  when,  as  the  result  of  some  slight  exposure  to  glare,  he  was  affected 
in  the  same  way  in  spite  of  wearing  Crookes '  glasses,  and  was  obliged 
to  give  up  his  work.  His  medical  attendant,  a  writer  on  psycho- 
logic subjects,  formed  the  same  view,  and  psychotherapy  was  ad- 
vised. 

This  is  a  common  incident  in  ophthalmic  practice,  and  it  is  impor- 
tant that  it  should  be  recognized,  so  that  it  may  be  appropriately 
treated.  Any  attempt  to  deal  with  such  cases  by  simply  assuring 
them  that  there  is  nothing  the  matter  with  them,  without  recognizing 
the  psychologic  aspect,  may  even  intensify  the  mischief.  Here  again 
we  see  that  ophthalmology  occupies  a  central  position,  with  the  added 
responsibility  which  arises  in  consequence. 

III.  PRONOUNCED  CASES  OF  MENTAL  DISEASES 
In  the  class  of  cases  which  would  be  certifiable  by  British  law  the 
ophthalmologist  is  not  likely  to  be  concerned  except  to  deal  with  in- 
cidental defects  which  call  for  attention.  Seeing,  however,  that  the 
major  psychic  diseases  are  usually  a  development  from  the  minor,  it 
may  be  possible  to  prevent  the  graver  forms  of  disorder  by  a  careful 
recognition  of  the  premonitory  symptoms. 

Seeing  that  visual  obsessions  are  a  common  element  in  these  cases, 
it  may  be  of  value  to  inquire  into  their  possible  origin. 

I  was  recently  asked  to  see  a  patient  who  was  in  a  state  of  marked 
dissociation,  with  visual  delusions.  She  stated  that  she  could  see 
moving  objects  in  the  dark  corners  of  the  room  taking  certain  definite 
shapes.  The  purpose  for  which  I  was  consulted  was  on  account  of 
defective  vision  and  the  possibility  of  prescribing  more  suitable 
glasses.  I  found  that  she  was  developing  opacities  in  the  lens  which 
were  mainly  in  the  form  of  minute  dots  scattered  throughout  the  lens. 
I  am  of  opinion  that  these  early  disturbances  of  vision  due  to  incipient 
cataract  are  quite  sufficient  to  form  imperfect  images  which  may  grad- 


Psychopathology  in  Ophthalmic  Practice  169 

ually  materialize  into  a  concept  of  defined  objects,  human  or  other- 
wise. 

Possibilities  of  the  development  of  serious  psychic  conditions  in 
connection  with  cataract,  and  indeed  in  other  cases  of  opacities  in  the 
media,  should  be  carefully  considered,  and  the  experience  of  ophthal- 
mologists as  to  the  relation  between  cataract  and  psychic  disorders 
might  be  a  valuable  contribution  to  psychologic  medicine.  In  a  case 
of  cataract  which  was  under  my  care  and  operated  upon  by  a  colleague 
of  mine  the  following  points  may  be  noted! 

Previous  to  the  onset  of  cataract  there  were  some  psychic  difficulties, 
with  prejudices  and  suspicions  which  were  evidently  morbid.  These 
were  accentuated  by  other  physical  infirmities,  including  deafness, 
and  with  the  onset  of  cataract  these  were  much  increased.  In  spite 
of  this  mental  condition,  and  indeed  with  the  hope  of  relieving 
in  some  measure  these  symptoms,  and  in  any  case  bringing  some 
relief  to  a  condition  of  pitiable  discomfort,  it  was  decided  to 
operate.  The  change  in  a  monotonous  life  of  removal  to  a  nursing 
home,  with  devoted  nursing,  had  a  great  effect  upon  the  patient. 
The  operation  was  most  successful,  and  though,  as  the  result  of 
starting  up  in  the  night  two  days  after  the  operation,  a  prolapse 
of  iris  occurred,  recovery  was  satisfactory.  During  the  after-treat- 
ment her  whole  outlook  to  life  seemed  to  change  and  the  improvement 
was  most  gratifying. 

Glaucoma  again  is  a  disease  in  which  the  severity  of  the  pain  and  the 
rapid  interference  with  sight  are  likely  to  lead  to  serious  forms  of  phobia. 
It  is  worthy  of  inquiry  in  these  cases  as  to  the  possibility  of  the  psychic 
attitude  complicating  the  physical  malady. 

These  are  matters  which  should  engage  our  serious  attention.  As 
ophthalmologists  we  are  brought  in  contact  with  disease  in  all  its  forms. 

As  we  have  already  stated,  ophthalmology  occupies  a  central  position 
in  medicine.  Let  us  prove  ourselves  worthy  of  the  charge  committed 
to  us.  It  may  be  that  we  may  be  able  to  give  substantial  assistance  to 
our  colleagues  who  are  grappling  with  the  obscure  disorders  which 
afflict  the  mind,  but  at  the  same  time  we  may  look  for  help  from  them 
in  many  of  the  mysterious  ailments  which  we  must  deal  with  in  our 
own  sphere. 

DISCUSSION 

DR.  GEORGE  F.  KEIPER  (Lafayette,  Ind.) :  This  is  an  extremely  interesting 
paper  because  it  calls  to  our  attention  things  which  every  ophthalmologist 
ought  to  know  from  the  standpoint  of  the  new  psychology,  which  starts  with 


170  CHARLES  F.  HARFOBD 

the  anatomy  and  physiology  of  the  central  nervous  system.  We  are  dealing 
not  with  chambers  of  the  mind,  but  with  nerve  cells.  In  the  cortex  of  the 
brain  there  are  from  three  billion  to  eight  billion  nerve  cells,  so  the  physiolo- 
gists have  estimated.  These  cells  are  the  repositories  of  impressions,  and 
when  they  are  properly  connected  up  we  have  that  which  is  called  knowledge, 
and  when  we  take  this  and  go  out  into  the  everyday  affairs  of  life  and  attempt 
to  apply  it  we  get  the  substance  which  we  call  wisdom,  and  that  varies,  of 
course,  in  different  individuals,  according  to  capacity  and  capability.  Of 
course,  we  know  what  some  of  these  nerve  cells  are  for — we  have  been  able 
to  work  out  what  we  call  localization  of  function,  as  along  the  fissure  of 
Rolando  and  in  the  occipital  lobes  which  localize  vision,  or  in  the  left  temporal 
sphenoidal  lobe,  where  several  years  ago  Dr.  Jack,  of  Boston,  and  I,  simul- 
taneously and  independently,  pathologically  located  it  by  operating  for 
abscess  of  that  lobe,  our  diagnoses  being  based  upon  the  symptoms  of  aphasia 
which  these  patients  manifested  after  mastoid  operation. 

There  has  been  no  better  definition  of  memory  than  that  given  by  Dr. 
Max  Nordau,  in  his  work  on  "Degeneration,"  a  number  of  years  ago,  when 
he  said  that  memory  is  nothing  more  nor  less  than  the  product  of  stored-up 
nerve-cell  action.  In  the  retina  of  each  eye  we  have  the  same  kind  of  nerve 
cells  as  in  the  cortices  of  our  brains,  and,  after  all,  vision  is  nothing  more  nor 
less  than  the  product  of  stored-up  nerve-cell  action.  The  eye  is  but  a  pro- 
longation of  the  brain  in  order  that  the  brain  may  come  in  contact  with  that 
form  of  motion  which  we  call  light  and  the  phenomena  produced  by  it  as  it 
comes  in  contact  with  all  nature. 

We  have  in  our  offices  the  same  kind  of  apparatus  that  the  physiologist 
uses  in  his  laboratory,  and  we  have  an  exceedingly  wide  and  interesting  field 
for  study  of  psychologic  states  in  relation  to  these  special  senses,  for,  after  all, 
it  is  through  the  medium  of  these  seven  or  eight  special  senses  that  we  get 
all  our  knowledge. 

MR.  J.  GRAY  CLEGG  (closing) :  Undoubtedly  there  are  many  cases  in  which 
we  have  difficulty  in  satisfying  our  patients,  the  patients  who  will  not  take 
cylinder  lenses,  who  get  comfort  only  when  the  cylinders  are  removed.  It 
seems  to  me  some  of  these  are  cases  where  the  psychic  influence  is  one  of  the 
main  factors.  Then  one  occasionally  comes  across  patients  who  have  two 
sets  of  glasses  from  the  same  prescription — they  are  perfectly  comfortable 
with  one  and  absolutely  uncomfortable  with  the  other,  and  nothing  will 
persuade  them  that  the  two  are  alike,  although  the  optician  and  oculist  are 
unable  to  see  the  difference.  There  again  we  have  the  psychic  element. 

In  the  case  of  muscce  volitantes  many  patients  are  seriously  perturbed  in 
their  mind  until  they  are  advised  not  to  look  at  floating  spots,  and  that  by 
suppressing  them  in  their  consciousness  they  will  have  a  return  to  a  state  of 
psychic  comfort  and  rest.  I  have  had  two  patients,  each  of  whom  complained 
of  seeing  his  nose  constantly.  The  only  remedy  was  either  to  suppress  that 
consciousness  or  to  have  a  radical  operation  undertaken.  Undoubtedly  in 
all  our  work' physicians  and  surgeons  are  constantly  exercising  the  factor  of 
suggestion  to  the  mind  of  the  patient.  Some  patients  are  satisfied  with 
advice  in  Europe;  others  come  to  America  to  secure  their  contentment.  I 
am  also  pleased  to  be  able  to  say  that  the  reverse  holds  good. 


NIJEVO  TRATAMIENTO  QUIRURGICO 
DEL  ESTRABISMO 

DR.  B.  CASTRESANA 

Madrid,  Espana 

El  problema  del  estrabismo  en  Espana  es  uno  de  los  capitulos  de 
nuestra  especialidad  que  menos  ha  progresado  en  la  ultima  decada 
del  siglo  que  corremos.  La  falta  de  cultura  en  las  masas  populares 
creyendo  de  buena  fe  incurable  su  enfermedad,  la  resistencia  constante 
para  dejarse  intervenir  quirurgicamente,  el  escaso  perfeccionamiento 
de  la  tecnica  operatoria  y  el  no  poder  asegurar  al  enfermo  el  exito 
seguro  y  definitive  despues  de  la  intervencion,  son  los  factores  que 
mas  poderosamente  han  contribuido  al  escaso  desarrollo  y  poca  in- 
tensidad,  que  tiene  el  estudio  de  la  correccion  estrdbica  en  nuestra 
patria. 

En  Espana  existen  multitud  de  enfermos  estrabicos;  pero  solo  se  pre- 
sentan  en  nuestras  cllnicas  escaso  numero  de  ellos,  con  la  pretension 
de  que  centremos  bien  sus  ojos  y  les  demos  vista  en  el  ojo  que  desvian, 
sin  practicarles  operacion  alguna. 

Las  intervenciones  quirurgicas  en  los  enfermos  estrdbicos  eran  esca- 
sisimas  hace  diez  anos,  aun  en  clinicas  numerosas,  como  la  mia.  Al- 
gunos  colegas  que  me  honraban  presenciando  mis  operaciones,  al 
manifestarme  deseo  de  ver  operar  un  estrabismo,  tenfa  que  decirles: 
Los  enfermos  estrabicos  no  se  dejan  operar  en  Espana,  no  por  pre- 
juicio  religioso,  como  opinaba  un  ilustre  colega  extranjero,  sino  por- 
que  creen  que  su  enfermedad  no  tiene  remedio. 

En  cierta  ocasion  aconsejaba  a  una  muchacha  de  diez  y  ocho 
se  dejase  operar  un  estrabismo  interno  pronunciadisimo  que  padecia. 
Despues  de  exponerle  varios  razonamientos  de  indole  estetica  y  fun- 
cional,  cuando  crei  haberla  convencido,  me  contesto  que  el  bizquear 
los  ojos  era  una  gracia  especial  que  no  estaba  dispuesta  a  corregir. 
Como  se  ve",  la  incultura  en  el  publico  resistiendose  sistemdticamente 
al  tratamiento  operatorio  ha  sido,  es  y  serd  en  el  porvenir,  la  causa 
precisamente  primordial  de  que  no  se  haya  hecho  en  nuestra  nacion 
un  estudio  acabado  y  perfecto  de  un  punto  tan  importante  como  es 
de  las  desviaciones  oculares. 

171 


172  B.  CASTRESANA 

Hay  que  confesar,  sin  embargo,  que  la  reaccion  ha  sido  tan  favorable 
para  nosotros,  por  el  e"xito  alcanzado  con  el  procedimiento  quirurgico 
que  practicamos  en  la  actualidad,  que  en  estos  ultimos  afios  el  ma- 
terial clinico  humano  ha  sido  mds  abundante,  dilatandose  mucho  el 
campo  de  nuestra  experifnentacion. 

Los  mismos  operados  de  estrabismo,  al  ver  corregida  su  desviacion 
oculaque  no  solamente  les  afeaba,  sino  que  tambien  era  en  mil  circun- 
stancias  motive  de  burlay  de  molestia  en  las  distintas  manifesta- 
ciones  de  su  vida  social,  han  sidojlos  m£s  entusiastas  propagandistas, 
aconsejando  a  otros  individuos  que  padecian  igual  defecto  se  dejen 
intervenir  quirurgicamente. 

La  desviacion  manifiesta  de  la  linea  visual  en  uno  de  los  ojos,  o  la 
falta  de  paralelismo  de  los  ejes  visuales,  es  el  defecto  ocular  que 
recibe  el  nombre  de  estrabismo.  Este  puede  ser  paralitico  o  con- 
comitante,  siendo  considerado  el  ultimo  como  el  verdadero  estrabismo, 
porque  sin  haber  paralisis  de  ningun  miisculo,  no  coinciden  las  dos 
lineas  visuales  en  el  mismo  objeto.  De  otra  parte,  en  esta  variedad 
estrdbica,  las  desviaciones  primarias  y  secundarias  con  iguales,  y  no 
existe  la  diplopia,  porque  generalmente  la  vision  imperfecta  que  el 
enfermo  tiene  en  uno  de  sus  ojos  constantemente,  hace  que  se  acos- 
tumbre  a  eliminar  -la  imagen  borrosa  del  ojo  estrabico. 

El  estrabismo  concomitante,  que  a  simple  vista  parece  monocular, 
porque  se  manifiesta  aparentemente  por  la  desviacion  de  uno  de  los 
ojos,  que  es  precisamente  el  que  tiene  menor  agudeza  visual,  es,  sin 
embargo,  bilateral  siempre,  y  el  ojo  desviado  represente,  segun  la 
opinion  de  Terrien,  la  suma  de  la  desviacion  de  ambos  ojos.  El 
estrabismo  alternante  y  la  igualdad  de  la  desviacion  primaria  y 
secundaria,  nos  prueba  la  existencia  de  la  bilateralidad  de  la  afeccion, 
y  a  la  vez  nos  demuestra  que  los  dos  globos  oculares  estan  afectados 
igualmente,  sin  que  exista  pardlisis  muscular  de  ningun  genero. 

Al  comentar  este  punto  del  estrabismo  el  doctor  Ribas  Valero,  uno 
de  nuestros  ilustres  colegas  que  mas  trabajos  ha  publicado  sobre  las 
desviaciones  estrabicas,  emite  la  opinion  de  Parinaud  y  dice;  "La 
causa  unica,  tanto  del  estrabismo  convergente  como  del  divergente, 
es  una  lesion  de  convergencia,  conservdndose  Integra  la  funcion  de 
direccion,  es  decir,  una  alteracion  del  aparato  de  la  vision  binocular, 
tanto  de  su  parte  sensitiva  como  de  su  parte  motora,  y  de  consig- 
uiente  de  las  conexiones  nerviosas  que  las  unen,  por  donde  normal- 
mente  se  transmiten  los  reflejos.  A  estas  alteraciones  primitivas  se 
agregan  posteriormente  otras  secundarias  que  las  modifican  y  alteran, 


Nuevo  Tratamiento  Quirurgico  del  Estrabismo 


173 


y  cambiando  su  naturaleza  producen  retracciones  fibrotendinosas." 
De  donde  se  deduce  que  para  el  citado  autor  frances,  el  estrabismo 
consiste  en  un  vicio  de  desarrollo  del  aparato  de  la  vision  binocular, 
que  afectara  a  la  parte  sensitiva  y  motora  a  la  vez,  y  que  ha  de  im- 
pedir  se  realice  la  convergencia  de  los  dos  ojos  sobre  el  objeto  que 
miramos.  No  debe  admitirse,  por  lo  tanto,  un  trastorno  muscular 
organico,  por  que  la  conservacion  de  los  movimientos  asociados  de 
direction,  la  existencia  del  estrabismo  alternante,  la  normalidad  del 
campo  de  mirada  cuando  se  inicia  la  afeccion,  prueban  todo  lo  con- 
trario. 


Fig.  1. — Debilitacion  al  musculo  antagonista. 


El  consignar  la  -bilateralidad  del  estrabismo  nos  es  indispensable  si 
hemos  de  razonar  el  tratamiento  que  empleamos  para  su  curacion  y 
nos  justifica  tambien  nuestra  intervention  quiriirgica  a  la  vez  en  los 
dos  ojos,  estando  en  este  punto  compenetrados  con  los  grandes 
clinicos  Panas  y  Landolt,  que  consejaban  corregir  siempre  bilateral- 
mente  el  estrabismo,  puesto  que  el  desequilibrio  ocular  afecta  a  los 
dos  ojos. 

El  estrabismo  tiene  tambien  su  tratamiento  medico,  habiendo  sido 
Javal  uno  de  sus  ma's  fervientes  partidarios,  pero  la  oclusion  de  un 
ojo  por  largo  tiempo,  el  uso  de  la  atropina,  de  los  vidrios  correctores 
del  defecto  de  refraction,  y  los  ejercicios  ortopticos  que  ocupan  un 


174 


B.  CASTRESANA 


lugar  muy  importante  con  relation  al  tratamiento  quirurgico  en  los 
primeros  aiios  de  iniciarse  el  estrabismo,  deben  sustituirse  por  la 
intervention  operatoria  si  no  produce  su  aplicacion  el  efecto  apetecido. 

Esto  no  quiere  decir  que  el  tratamiento  quirurgico  pueda  curar  por 
si  solo  un  estrdbico,  porque  lo  unico  que  hace  es  corregirle  su  estra- 
bismo aparente,  sin  intervenir  en  las  funciones  de  asociacion  visual, 
susceptibles  de  modificar  por  los  medics  opticos  que  indicabamos 
anteriormente. 

Claro  estd  que  no  todos  los  estrabismos  son  curables,  entendiendo 
por  estos  aquellos  a  quienes  se  pueda  devolver  la  vision  binocular,  pero 


Fig.  2. — Reseci6n  de  un  trozo  de  la  conjuntiva  que  deja  al  descubierto  la  inserci6n 
muscular  en  la  escler6tica. 

todos  se  puede 'decir  que  son  corregibles,  es  decir,  que  mediante  la 
intervention  quirurgica  podemos  suprimirles  el  estrabismo  aparente, 
y  el  enfermo  queda  muy  satisfecho  desde  el  momento  que  le  hemos 
hecho  una  buena  correction  estetica,  que  haga  desaparecer  su  defecto, 
aun  cuando  no  consiga  la  vision  binocular  que  nunca  tuvo. 

Nosotros  hemos  de  procurar  la  curacion  verdadera  del  estrabismo 
mediante  el  tratamiento  quirurgico  y  6ptico  consecutivo;  pero  si 
fuera  imposible  conseguir  la  vision  binocular,  nos  conformaremos  con 
haber  mejorado  la  estetica  facial  del  enfermo,  que  tiene  capital  im- 
portancia,  sobre  todo  cuando  se  trata  del  sexo  femenino. 


Nuevo  Tratamiento  Quirurgico  del  Estrabismo 


175 


En  el  siglo  XVIII  es  cuando  parece  germino  la  idea  de  poner  re- 
medio  quirurgico  a  la  desviacion  estrdbica,  relatando  Eschenbach, 
que  un  ingles  llamado  Taylor  curaba  el  estrabismo,  plegando  la  con- 
juntiva  con  unos  hilos  de  seda,  pero  mo  esta  probado  que  seccionase 
el  musculo,  como  opinan  algunos  autores.  La  primitiva  idea  de  cura- 
cion  del  estrabismo  partio  de  Taylor,  pero  indudablemente  el  trata- 
miento  que  aplico  fue  muy  incomplete. 

Es  preciso  que  transcurra  casi  un  siglo,  hasta  el  afio  1838,  para  que 
se  hable  de  nuevo  de  la  operacion  del  estrabismo  por  Stromeyer,  quien 
hizo  una  description  detallada  de  la  tecnica  operatoria,  seccionando  el 


Fig.  3. — Cogida  del  musculo  con  la  f^nra  de  Prince,  a  una  distancia  de  su  inserci6n 
tendinosa,  proportional  al  grado  de  estrabismo. 

musculo.  Pero  Stromeyer  realize  sus  experiencias  en  el  cadaver, 
siendo  Paulin  en  1839  el  primero  que  practice  la  operacion  en  el  ser 
viviente.  Casi  al  mismo  tiempo  Dieffenbach  seccionaba  el  musculo 
en  su  portion  posterior,  realizando,  por  lo  tanto,  una  miotomia,  hasta 
que  Guerin  en  1840  hizo  la  tenotomia,  que  vino  a  sustituir,  aquella, 
gracias  a  los  trabajos  de  Bonet  de  Lion. 

Los  resultados  obtenidos  con  la  miotomia  y  la  tenotomia  desani- 
maron  a  los  operadores.  La  primera  producia  un  estrabismo  para- 
litico,  y  la  segunda  a  la  larga  el  estrabismo  en  sentido  contrario. 
Diez  anos  mas  tarde,  Jules  Guerin  ideo  el  avance  muscular  para  con- 


176 


B.  CASTRESANA 


trarrestar  los  estrabismos  producidos  por  la  miotomia  y  tenotomia, 
mal  reglada  por  aquel  entonces. 

En  los  anos  1860  al  62  es  cuando  Graefe,  Critchett,  Agnew,  Cunier, 
Lucien,  Boyer  y  Bachm,  se  ocuparon  de  estudiar  con  detalle  el  avanza- 
miento  muscular,  perfeccionaron  la  t£cnica  operatoria,  y  sustituyeron 
el  avance  simple  por  el  avance  con  reseccion  parcial  del  tendon. 

Mas  tarde,  el  afio  1883,  Wecker  ide6  el  plegado  del  musculo  y  prac- 
tice el  avance  capsular,  metodo  que  aun  en  la  actualidad  es  seguido 
por  ilustres  colegas  espafioles  y  extranjeros.  En  1890  Parinaud 


Fig.  4. — El  musculo  sujeto  por  la  pinza,  se  secciona  por  delante  de  ella  quedan- 
dose  un  trozo  suelto  mayor  o  menor  segiin  la  desviaci6u  estrabica  unido  a  la 
esclerotica  por  su  insercion  anterior. 

sustituye  la  tenotomia  por  los  desbridamientos  capsulares  amplios, 
y  Lagleyze  propone  dos  anos  mds  tarde  el  acortamiento  muscular. 
Por  ultimo  Landolt  en  1894  dice  que  el  avance  muscular  aumenta  la 
energia  del  musculo  y  aconseja  se  practique  el  avance  bilateral. 

En  realidad,  los  distintos  procedimientos  quinirgicos  propuestos 
para  corregir  el  estrabismo  se  pueden  reunir  en  dos  grandes  grupos: 
En  el  primero,  pueden  congregarse  los  metodos  que  tienen  por  objeto 
disminuir  la  traccion  ejercida  por  el  recto  interne,  externo,  o  su  cdp- 
sula,  segun  que  el  estrabismo  sea  convergente  o  divergente.  Entre 
estos  consignaremos  la  tenotomia  y  los  desbridamientos  de  Parinaud. 


Nuevo  Tratamiento  Quirurgico  del  Estrabismo 


111 


En  el  segundo,  incluiremos  aquellas  intervenciones  quiriirgicas  que 
tienden  a  aumentar  la  traccion  ejercida  por  el  recto  externo  y  su 
capsula,  cuahdo  se  trata  del  estrabismo  interne,  o  viceversa,  si  la 
desviacion  estrabica  es  externa.  Este  resultado  se  pretende  con- 
seguir  mediante  el  acortamiento  y  los  avanzamientos  musculares  y 
capsulares. 

Al  estudiar  cada  una  de  las  operaciones  propuestas  en  los  dos 
grupos  precedentes,  no  hemos  de  exponer  su  tecnica  operatoria, 
descrita  en  las  obras  y  monografias  de  nuestra  especialidad  que  tratan 


Fig.  5. — Sutura  romboidal  compuesto  de  tres  puntos,  uno  central  y  dos  laterales 
desviados  hacia  el  ecuador  del  globo  ocular  y  que  pueden  oblicuarse,  si  el  estra- 
bismo es  algo  superior  o  inferior. 

del  estrabismo :  me  voy  a  limitar  solamente  a  exponer  sus  resultados 
y  consecuencias  fisiologicas,  despues  de  haber  pasado  algun  tiempo 
de  la  intervencion. 

Modificada  y  reglada  por  Bonet  de  Lion  la  tecnica  de  la  tenotomla, 
que  practice  primero  Stromeyer  y  despues  Dieffenbach,  se  puede  decir 
que  ha  sido  la  operacion  que  mas  frecuentemente  se  ha  practicado 
contra  el  estrabismo,  a  pesar  de  tener,  a  mi  juicio,  mds  inconvenientes 
que  ventajas. 

Es  indudable  que  la  tenotomia  produce,  inmediatamente  despues 
de  practicada,  un  enderezamiento  del  globo  ocular  desviado,  pero  en 
12 


178 


B.  CASTRESANA 


general  el  enderezamiento  no  persiste  en  los  dias  sucesivos,  pudiendo 
algunas  veces  desaparecer  por  complete.  Solo  en  casos  muy  espe- 
ciales  y  en  tenotomias  muy  amplias  se  ha  conseguido  alguna  vez  una 
correccion  de  10  a  12°.  Si  no  hemos  suturado  la  membrana  con- 
juntival,  la  caruncula  lagrimal  se  hunde,  debido  a  que  la  conjuntiva 
del  dngulo  interne  adherida  a  los  tejidos  profundos,  es  arrastrada  por 
el  musculo  retractado.  Se  presenta  tambien  una  exoftalmia  posto- 
peratoria  que  si  es  bastante  acentuada  produce  una  deformidad  muy 
desagradable,  que  si  bien  podemos  corregir  con  una  cantoplastia  del 
ojo  del  lado  opuesto,  no  deja  de  ser  una  complication  digna  de  tenerse 
en  cuenta. 


Fig.  6. — Sitio  de  uni6n  de  los  puntoos  de  sutura  despues  de  verificar  el  avance 
indirecto,  fijando  los  extrenos  de  los  puntos  de  seda  con  un  esparandvayso  en  la 
parte  externa  o  interna,  segun  el  estrabismo  que  se  opere. 

Los  inconvenientes  lejanos  de  la  tenotomia  son  todavia  mds  graves. 
Lo  ma's  frecuente  es  que  la  vision  binocular  no  se  restableza  despues 
de  la  operation,  y  que  sobrevenga  el  relajamiento  espontaneo  de  la 
conyergencia,  dando  lugar  a  un  estrabismo  externo  de  un  efecto  ma's 
desagradable  que  la  desviacion  ocular  interna  que  tenia  el  enfermo, 
afectado  de  estrabismo  convergente. 

Por  otra  parte,  la  tenotomia  del  recto  interne  produce  un  retroceso 
en  la  insertion  del  tendon  muscular,  que  dard  origen  a  una  insufi- 
ciencia  del  musculo,  y,  por  consiguiente,  de  la  misma  convergencia. 
No  obstante,  la  tenotomfa  prudente  practicada  en  el  nino  que  tenga 
buena  agudeza  visual  del  ojo  desviado  puede  en  algun  caso  muy  raro 
determinar  el  enderezamiento  del  globo  ocular,  establecer  la  vision 


Nuevo  Tratamiento  Quirurgico  del  Estrabismo  179 

binocular  y  conseguir  la  verdadera  cura  del  estrabismo;  pero  estos 
casos  son  excepcionales. 

Lo  que  ocurre  generalmente  es  que,  si  bien  al  principio  el  endereza- 
miento  es  bastante  aceptable,  a  medida  que  el  nifto  crece  sin  que  se 
restablezca  la  vision  binocular,  de  una  parte  el  relajamiento  espon- 
tdneo  de  la  convergencia  y  de  otra  efecto  de  la  tenotomia,  hace  que  se 
presente  un  estrabismo  secundario  externo  que  anula  por  complete 
la  correccion  estetica  que  conseguimos  en  la  nifiez. 

El  campo  de  mirada  de  los  operados  de  tenotomia  se  observara 
que  se  encuentra  disminuido  en  la  abduccion  del  globo  ocular,  y,  en 
cambio,  no  se  encuentra  aumentado  en  la  abduccion.  Es  verdad 
que  el  ojo  operado  presenta  un  enderezamiento  en  los  movimientos 
correspondientes  a  la  esfera  de  accion  del  musculo  tenotomizado,  pero 
es  un  enderezamiento  aparente,  realmente  debil,  al  querer  seguir  a  su 
congenere,  no  tardando  en  presentarse  la  falsa  proyeccion  y  la  desar- 
monia  entre  las  excursiones  del  globo  ocular. 

La  vision  binocular  no  se  puede,  por  lo  tanto,  restablecer,  puesto 
que  falta  la  armonia  indispensable  en  los  movimientos  de  lateralidad 
y  convergencia  de  los  dos  ojos.  Si  la  doble  imagen  generalmente  no 
aparece,  es  porque  existe  una  ambliopia  en  el  ojo  tenotomizado,  con 
neutralizacion  de  la  imagen  percibida.  Aunque  hayamos  conseguido 
mejorar  la  agudeza  visual  del  ojo  operado,  y  goce  de  una  vision  sufi- 
ciente,  veremos  que  no  es  posible  se  realice  la  vision  binocular,  porque 
entonces  aparecera  una  diplopia  cruzada  en  el  campo  de  accion  del 
musculo  tenotomizado,  y  como  la  amplitud  de  la  convergencia  se  dis- 
minuye  por  haber  debilitado  el  recto  interne,  la  diplopia  se  presentard 
en  cuanto  el  enfermo  quiera  hacer  uso  de  la  vision  proxima.  Por  eso 
dice  Landolt  que  el  efecto  de  la  tenotomia  separando  el  musculo  recto 
interne  del  globo  ocular  es  el  mismo  que  el  de  una  paresia,  puesto  que 
da  lugar  a  una  insuficiencia  de  convergencia,  "y,  sin  embargo,  el 
nombre  sol  de  convergencia  decia  que  no  era  preciso  tomar,  sino 
anadir;  no  debilitar,  sino  mds  bien  reforzar." 

El  efecto  de  la  tenotomia  en  el  estra6ismo  divergente,  se  traduce 
tambien  por  un  enderezamiento  del  ojo  desviado;  pero  como  en  el 
estrabismo  divergente  las  desviaciones  son  muy  pronunciadas,  el 
enderezamiento  que  se  consigue  tenotomizando  es  generalmente  muy 
insuficiente.  Como  persiste  la  divergencia,  cuando  el  enfermo  quiere 
hacer  uso  de  su  vision  proxima,  se  presenta  la  diplopia  cruzada,  que 
sera  homonima  si  mira  el  operado  de  lejos,  parecie"ndonos  entonces 
que  su  bizqueza  se  interna. 


180  B.  CASTRESANA 

Se  comprende  que  asi  suceda;  porque  si  el  estrabismo  divergente 
resulta  de  la  debilidad  de  inervacion  del  recto  interne,  y  hemos  teno- 
tomizado  el  recto  externo  paresiandole,  no  podrd  contraerse  lo  sufi- 
ciente  en  la  vision  lejana  para  relajar  la  convergencia  y  tendrd  nece- 
sariamente  que  presentarse  un  estrabismo  convergente  con  diplopia 
homonima,  como  deciamos  anteriormente.  Charles  Giraud  sintetiza 
su  opinion  diciendo:  "Para  tener  derecho  a  tenotomizar  el  musculo 
recto  externo  de  un  ojo  cuya  vision  es  suficiente,  haria  falta  que  este 
ojo  presentase  un  gran  exceso  de  divergencia  activa."  Onfray  se 
expresa  en  estos  te'rminos:  "La  tenotomia  es  una  operacion  peligrosa, 
cuyo  resultado  no  puede  ser  absolutamente  previsto,  y  la  tenotomia 
del  recto  externo  es  una  operacion  casi  siempre  intitil  y  frecuentemente 
perjudicial."  For  ultimo,  Parinaud  emite  su  parecer  en  esta  especie 
de  corolario:  "A  medida  que  se  adquiere  experiencia,  a  medida  sobre 
todo  que  se  persigue  en  el  tratamiento  del  estrabismo,  no  solamente  el 
enderezamiento  de  los  ojos,  sino  el  restablecimiento  de  la  vision 
binocular,  tropieza  uno  con  mas  y  mas  inconvenientes  del  recula- 
miento  muscular." 

Cuenta  Paul  Charles  Giraud,  que  habiendose  encontrado  un  dia 
su  maestro  Rochon  Duvigneaud  con  el  celebre  anatomico  Farabouf 
le  dijo  este  en  tono  sarcastico:  "Se  cortan  todavia  los  musculos  en 
Oftalmologia." 

En  los  Archives  de  Oftalmologia  Hispano-Americanos  del  mes  de 
Junio  pasado,  el  profesor  Landolt,  al  hablar  de  los  efectos  de  la  teno- 
tomia, dice  que  produce  la  desviacion  del  ojo  en  direccion  opuesta, 
la  limitacion  de  la  excursion  y  la  falsa  proyeccion  en  direccion  de  la 
acci6n  del  musculo.  Al  tenotomizar  los  rectos  internos  en  el  estra- 
bismo convergente  concomitante,  se  crea  una  insuficiencia  de  con- 
vergencia que  se  opone  al  restablecimiento  de  la  vision  binocular, 
ademas  del  efecto  antiestetico  resultante  de  la  retraccion  de  la  ca- 
runcula.  Si  por  el  contrario  tenotomizamos  los  rectos  externos  en  el 
estrabismo  divergente,  producira  por  igual  causa  los  mismos  efectos 
perjudiciales.  Estos  hechos,  dice  Landolt,  son  la  condenacion  de  la 
tenotomfa. 

Esta  intervenci6n  resultaria  todavia  mas  perturbadora,  a  mi  juicio, 
practicandola  como  intervencion  unica  en  el  ojo  que  no  se  desvia, 
segiin  aconseja  Battremieux,  el  cual  corrige  indirectamente  todo  el 
estrabismo  operando  sobre  el  ojo  sano,  en  lugar  de  limitarse  a  corregir 
en  este  ojo  la  mitad  o  poco  mas,  y  el  resto  en  el  ojo  desviado.  Este 
procedimiento  produce  en  un  estrabismo  convergente,  que  es  la 


Nuevo  Tratamiento  Quirurgico  del  Estrabismo  181 

variedad  donde  emplea  su  me'todo,  una  abduccion  del  ojo  fijador 
igual  a  la  abduccion  o  convergencia  estrabica.  De  este  modo,  cuando 
fije  en  primera  posici6n  con  el  ojo  operado,  tendrd  que  efectuar  un 
movimiento  igual  al  grado  de  desviacion  corregida,  y  en  virtud  de  la 
inervacion  recuperada  por  el  ojo  fijador,  para  trasladarse  desde  el 
sitio  donde  fue  llevado  por  la  tenotomia,  hasta  colocarse  en  primera 
posicion,  el  ojo  desviado  que  permanecia  indiferente  en  su  posicion 
anormal,  se  enderezard,  por  sinergia  hasta  que  alcance  la  primera 
posicion.  Este  procedimiento  no  ha  sido  practicado  mas  que  por  su 
autor. 

De  otra  parte,  el  efecto  corrector  de  la  tenotomia  no  se  interpreta 
de  igual  modo  por  los  diversos  autores  que  se  han  ocupado  de  esta 
cuestion.  Las  dos  hipotesis  que  mds  partidarios  han  tenido,  son  la 
de  Parinaud  y  la  de  Motais.  Para  el  primero,  la  tenotomia  remedia 
un  trastorno  de  inervacion  y  obra  debilitando  el  rmisculo  que  retrocede 
de  su  insercion.  Esta  debilidad,  esta  insuficiencia  muscular,  se 
podria  explicar  por  la  disminucion  de  extension,  a  consecuencia  del 
enroscamiento  del  musculo.  En  cambio,  el  segundo  fundamente  su 
opinion  en  el  papel  importantisimo  que  juegan  las  aletas  ligamentosas 
de  la  cdpsula  Tenon,  que  se  prolongan  hasta  el  borde  orbitrario  cor- 
respondiente  donde  tienen  su  insercion. 

Estas  aletas,  supone  el  profesor  Motais,  que  limitan  la  contraccion 
de  los  musculos,  porque  son  susceptibles  de  alargarse  en  cierta  medida 
cuando  practicamos  la  tenotomia.  En  virtud  de  este  alargamiento, 
la  aleta  dispondrd,  por  consiguiente,  de  una  porcion  menor  susceptible 
a  ceder  en  la  contraccion  muscular.  El  musculo  tendra  que  luchar 
desde  el  principio  de  su  contraccion,  con  una  tension  mayor  de  la 
aleta  ligamentosa,  facilmente  comprensible,  por  haber  retrocedido  el 
tendon,  al  separarse  de  la  membrana  esclerotical.  Esto,nos  explicaria 
la  disminucion  en  la  excursion  del  ojo,  y  la  debilidad  o  insuficiencia 
del  musculo  tenotomizado. 

El  Dr.  Lagleyze  no  acepta  la  hipotesis  de  Motais,  porque  funda- 
menta  sus  experiencias  en  diseccion  de  animates  muertos,  es  decir,  en 
las  peores  condiciones  para  resolver  un  problema  de  dindmica  muscu- 
lar, y  ademds,  porque  dice  que  el  dibujo  presentado  por  Motais  para 
sus  explicaciones  no  coincide  con  los  casos,  porque  la  figura  deberfa 
representar  en  iguales  condiciones  estdticas  de  sus  musculos,  la  posi- 
cion del  estrabismo  y  la  de  su  correccion,  para  observar  el  estado  del 
musculo  y  de  su  aleta  ligamentosa,  antes  y  despue*s  de  la  operation. 

No  hemos  nosotros  de  seguir  las  disposiciones  cientificas  que  hace 


182  B.  CASTRESANA 

tan  sabio  profesor  con  respecto  a  la  interpretacion  de  los  esquemas 
indicados,  puesto  que  no  es  de  nuestra  incumbencia  en  este  momento ; 
solo  daremos  a  conocer  sinteticamente  su  opinion,  que  al  fin  y  al  cabo, 
es  una  hipotesis  mas  en  el  campo  de  la  ciencia. 

En  la  tenotomia  dice :  "  Lo  primero  que  se  produce  es  un  endereza- 
miento  del  ojo.  El  musculo  antagonista  libre  de  la  contractura  del 
musculo  tenotomizado,  disminuye  su  longitud,  por  su  propia  conici- 
dad.  Abierta  la  capsula  de  Tenon  al  practicar  la  intervencion,  per- 
mite  que  la  elasticidad  propia  de  la  hoja  periorbitaria  de  esta  capsula, 
se  retracte  sobre  el  borde  orbitario  cbrrespondiente  al  lado  operado, 
y  el  globo  del  ojo,  una  vez  disminuidas  las  adherencias  que  le  detenian 
en  el  sitio  del  tendon  cortado,  se  dirige  hacia  adelante,  volviendo  al 
mismo  tiempo  hacia  el  lado  opuesto."  El  resultado,  por  lo  tanto, 
despues  de  la  tenotomia,  sera  que  el  musculo  conserva  sus  dimensiones 
anteriores,  obedece  como  antes  al  mismo  influjo  nervioso,  no  esta 
debilitado,  y  tiene  la  misma  contractilidad,  o  mayor  que  antes  de  la 
operacion.  En  la  tenotomia  de  un  musculo  el  que  se  acorta  es  el 
antagonista,  en  una  cantidad  proporcional  correspondiente  a  la  cor- 
reccion  del  estrabismo,  quedando  el  musculo  tenotomizado  con  la 
misma  longitud  que  antes  de  la  intervencion. 

En  vista  de  los  inconvenientes  que  tiene  le  tenotomia,  se  le  ha 
querido  sustituir  por  otros  procedimientos  quirurgicos,  que  respetando 
la  insercion  anterior  del  musculo  no  la  debilite.  Empecemos  por  los 
desbridamientos  capsulares  de  Parinaud. 

En  el  afto  1890,  Parinaud  ideo  su  operacion  de  los  desbridamientos, 
que  vino  practicando  hasta  su  muerte,  como  verdadero  sustituto  de  la 
tenotomia.  El  ilustre  oculista  fundamentaba  su  intervencion  quirur- 
gica,  en  que  la  extensibilidad  del  musculo  esta  sujeta  por  sus  co- 
nexiones  con  la  cdpsula,  cuyas  suspensiones  fibrosas  podrfan  en  los 
estrabismos  antiguos  presentar  adherencias  patologicas,  que  es  precise 
liberar  para  el  enderezamiento  del  globo  ocular. 

El  desbridamiento  capsular  de  un  musculo  ha  de  ir  acompanado 
siempre  del  avance  del  antagonista  resultando  la  operacion  combinada, 
puesto  que  se  interviene  en  los  demds  musculos  a  la  vez. 

Segiin  el  Dr.  Parinaud,  la  operacion  combinada  producira  un  en- 
derezamiento inmediato  de  25°  a  30°  que  yo  no  he  podido  compro- 
bar.  Es  precise  tengamos  una  asepsia  rigurosa  y  no  traumaticemos 
mucho  en  la  operaci6n,  porque  nos  puede  venir  una  retraccion  in- 
flamatoria  secundaria,  que  neutralice  por  complete  el  efecto,  que  en 
un  principio  se  consiguio  con  el  acto  quirurgico.  Este  procedimiento 


Nuevo  Tratamiento  Quirurgico  del  Estrabismo  183 

tiene  la  ventaja  de  que  no  modifica  la  movilidad  del  globo  ocular 
hacia  su  parte  interim,  y  por  lo  tanto,  no  se  opone  al  restablecimiento 
de  la  vision  binocular,  porque  no  hace  mas  que  librar  al  musculo  de 
sus  adherencias  respetando  su  insercion  anterior. 

Solo  a  titulo  de  curiosidad  merece  consignarse  el  alargamiento 
muscular  de  Landolt,  puesto  en  vigor  el  ano  1905.  En  este  pro- 
cedimiento  como  lo  indica  su  nombre,  el  objeto  es  alargar  el  musculo 
encogido,  o  mejor  dicho  acortarle,  respetando  su  insercion  anterior. 

En  ocasiones,  en  vez  de  alargar  el  musculo  se  le  secciona,  y  entonces 
nos  encontramos  con  los  graves  inconvenientes  de  la  miotorma  de 
Dieffenbach,  y  asi  lo  comprendio  el  mismo  Landolt  al  limitar  mucho 
sus  indicaciones. 

Julio  G.  Guerin,  en  1849,  dio  a  conocer  el  nuevo  procedimiento 
quirurgico  del  avance  muscular,  con  el  que  pretendia  corregir  el  estra- 
bismo  secundario  consecutive  a  tenotomias  desgraciadas.  En  1872 
Critchett  modifico  su  tecnica  empleandole  como  tratamiento  de  las 
desviaciones  oculares  primitivas,  y  Wecker  en  1883,  en  vez  de  separar 
el  musculo  de  su  insercion  tendinosa,  lo  plegaba  sencillamente,  practi- 
cando  un  avanzamiento  cdpsulomuscular,  asociado  casi  siempre  a  la 
tenotomia  del  musculo  antagonista,  que  fue  suprimida  mas  tarde  por 
Landolt. 

Este  colega,  partidario  entusiasta  de  los  avanzamientos,  desecha 
las  tenotomias  y  no  se  contenta  solo  con  el  aislamiento  del  tendon, 
sino  que  reseca  la  parte  anterior  del  musculo,  para  llevarle  mas  cerca 
del  limbo  esclerocorneal,  constituyendo  la  operacion  del  avanzamiento 
con  reseccion  muscular. 

El  procedimiento  de  Wecker  se  caracteriza  por  la  plegadura  del 
musculo  y  de  su  capsula,  respetando  la  insercion  tendinosa  de  los 
rectos.  El  efecto  corrective  que  conseguimos  eon  esta  operacion 
varia  segun  la  mayor  o  menor  extension  del  plegamiento  y  segun  la 
combinemos  o  no  con  la  tenotomia.  Si  practicamos  el  procedimiento 
cldsico  de  Wecker,  avanzamiento  con  tenotomia  del  antagonista,  la 
desviacion  estrabica  se  corregira  de  15  a  20°,  porque  el  avance  cap- 
sular  aumenta  la  accion  correctora  de  la  separacion  muscular,  pero  en 
cambio  disminuye  la  abduccion  y  la  amplitud  de  la  convergencia, 
factores  que  mas  tarde  vendran  a  perturbar  la  vision  binocular. 

Si  hacemos  caso  omiso  de  la  tenotomia,  e  intentamos  corregir  el 
estrabismo  empleando  el  avance  capsular  bilateral,  observaremos  que 
no  corrige  mas  de  10  a  12°,  pero  no  perturba  la  convergencia,  y  puede 
producir  la  curacion  verdadera  de  estrabismos  muy  poco  pronunci- 


184  B.  CASTBESANA 

ados.  La  correccion  que  produce  el  avance  capsular  bilateral  es, 
por  lo  tanto,  muy  limitada  y  se  disminuye,  porque  al  quitar  los  puntos 
de  sutura  desaparece  la  plegadura  del  musculo.  La  cdpsula  tenoniana 
no  queda  avanzada  segiin  parecen  demostrar  las  operaciones  hechas 
por  Halt  en  los  animales.  Es  posible,  dice  Parinaud,  que  los  hilos  de 
sutura  determinen  en  el  musculo  y  la  cdpsula  una  ligera  retraction 
cicatricial.  En  suma,  el  inconveniente  del  avance  cdpsulomuscular 
es  que  no  corrige  mds  que  las  desviaciones  estrabicas  muy  d^biles. 
En  mi  humilde  opinion,  de  iguales  defectos  adolece  el  acortamiento 
muscular  de  Lagleyze  aun  asociado  a  la  tenotomia.  Solo  corrige  las 
desvdciones  estrdbicas  pequenas,  si  no  se  practican  amplias  tenoto- 
mias  con  todas  sus  consecuencias.  Los  estrabismos  pronunciados 
aunque  parecen  corregirse  despues  de  la  intervention,  vuelven  a 
reaparecer  de  nuevo  con  igual  intensidad  al  cabo  de  cierto  tiempo. 

La  verdadera  intervention  quirurgica  que  merece  el  nombre  de 
avanzamiento  muscular,  se  realiza  cuando  separamos  el  musculo  de 
su  insertion  y  lo  trasplantamos  mas  cerca  del  limbo  esclerocorneal. 
Las  modificaciones  que  se  ban  hecho  en  la  tecnica  cldsica  del  avanza- 
miento por  Jocqs,  no  resecando  la  conjuntiva;  el  avanzamiento  en 
A  de  Valude;  el  avanzamiento  y  sus  cdpsulas  en  sutura  por  Rochon 
Duvigneaud,  y  la  sustitucion  de"  los  hilos  de  seda  por  tendones  de 
renguifo,  para  suturar  la  esclerotica  y  no  tener  que  quitar  los  puntos 
de  sutura,  empleados  por  Terson,  han  dado  casi  los  mismos  resultados. 
El  procedimiento  del  avance  musculocapsular  con  sutura  especial 
de  Jocqs,  presentado  en  el  Congreso  de  1903,  y  los  distintos  trabajos 
de  este  ilustre  publicista,  dados  a  conocer  los  afios  1904  y  1909  en  La 
Clinique  Ophtalmologique,  hicieron  que  se  emplease  su  tecnica  opera- 
toria  por  algunos  oculistas  con  resultados  halaguenos  en  los  estrabis- 
mos d^biles.  En  los  pronunciados,  aconseja  Jocqs  que  se  practique 
una  pequena  tenotomia  del  musculo  antagonista,  por  resultar  poco 
energico  su  procedimiento. 

En  el  avance  muscular  admite  Motais  el  aumento  de  la  fuerza  y  la 
extension  del  musculo  avanzado,  funddndose  en  la  hipotesis  de  que 
la  aleta  ligamentosa  del  musculo  que  se  avanza,  se  relaja.  Para 
demostrar  su  opinion  presenta  unos  dibujos  artificiosos  que  segun 
Lagleyze  tienen  el  mismo  error  senalado  en  los  esquemas  de  la  teno- 
tomia. La  aleta  ligamentosa  antes  y  despue's  del  avance  muscular, 
ocupa  el  mismo  sitio  en  el  espacio  orbitario,  dice  Lagleyze,  y,  por 
consiguiente,  las  eletas  no  pueden  influir  aumentando  la  action  del 
musculo.  Este  no  avanza  en  el  espacio  orbitario  como  parece  des- 


Nuevo  Tratamiento  Quirurgico  del  Estrabismo  185 

prenderse  de  las  figuras  de  Motais,  porque  seria  precise  para  ello  que 
el  globo  ocular  se  mantuviso  fijo  y  no  estuviera  suspendido  en  la 
cavidad  orbitaria,  como  una  especie  de  articulacion  del  ge"nero  de  las 
enartrosis. 

Para  el  profesor  de  la  Universidad  de  Buenos  Aires  el  musculo  no 
aumentara  la  fuerza,  por  crearse  un  nuevo  obstdculo  en  el  aumento 
del  antagonista,  que  ha  de  neutralizar,  empleando  parte  de  su  energia, 
lo  que  no  ocurria  antes  de  la  intervencion,  puesto  que  el  antagonista 
en  posicion  estrdbica  tenfa  un  estado  de  menor  tension.  Si  nosotros 
no  aumentamos  la  fuerza  de  un  musculo  debilitado,  con  el  avanza- 
miento  del  mismo,  creo  que  podemos  por  lo  menos  aumentar  la 
eficacia  de  su  contraction,  como  afirma  Landolt  en  su  reciente  trabajo, 
publicado  en  los  Archivos  de  Oftalmologla  Hispano- Americanos  en  el 
mes  de  Junio  del  afio  anterior.  Al  avanzar  el  musculo,  aumentamos 
la  extension  de  contacto  sobre  el  globo  ocular,  lo  que  producira  un 
efecto  suficiente,  a  pesar  de  su  fuerza  escasa. 

El  avance  muscular  origina  por  si  solo  un  enderezamiento  del 
globo  ocular,  sin  producir  exoftalmia  ni  deformation  de  la  hendidura 
palpebral.  No  disminuye  la  abduction,  y  la  amplitud  de  la  abduc- 
tion se  ha  conservado.  El  estrabismo  secundario  no  se  presenta  en  el 
transcurso  del  tiempo,  y  con  ejercicios  constantes  de  vision  binocular, 
pueden  algunos  casos  de  estrabismo  muy  poco  pronunciado  llegar  a 
la  verdadera  curacion.  El  inconveniente  de  este  procedimiento  es 
que  no  produce  mas  que  un  enderezamiento  insuficiente,  no  sirviendo 
para  los  estrabismos  de  un  grado  elevado. 

Para  las  desviaciones  estrabicas  muy  pronunciadas  Landolt  reco- 
mienda  las  resecciones  parciales  combinadas  con  el  avanzamiento, 
me'todo  en  realidad  que  se  diferencia  muy  poco  en  su  te"cnica  del 
avanzamiento  muscular  sencillo. 

El  enderezamiento  que  se  consigue  es,  sin  embargo,  mejor,  y 
aumenta  tanto  ma's  cuanto  mayor  sea  la  resection  muscular  que 
practiquemos,  sin  que  se  observe  estrabismo  secundario.  La  cor- 
recci6n  es  mds  acentuada,  y,  con  el  empleo  de  los  medios  opticos  y 
ortopticos,  se  consigue  en  algunos  casos  la  verdadera  curacion.  Esta 
se  comprende,  si  tenemos  en  cuenta  que  el  miisculo,  despues  de  la 
intervencion  quirurgica,  no  solo  queda  arrollado  sobre  el  globo  ocular, 
sino  acortado,  lo  que  acrecienta  su  action,  sin  perjudicar  el  funcion- 
amiento  del  antagonista,  para  que  pueda  realizarse  la  vision  binocular. 
Desgraciadamente,  la  correction  no  suele  ser  duradera  en  la  mayor 
parte  de  los  casos,  cuando  el  avance  con  reseccion  ha  sido  monocular, 


186  B.  CASTRESANA 

piles  bien  pronto  vuelve  a  presentar  de  nuevo  el  desequilibrio  muscu- 
lar, cuando  nuestra  intervention  se  limita  solo  a  un  ojo. 

Es  verdad  que  aparentemente,  siendo  solo  uno  el  ojo  desviado, 
parecer  natural  que  la  operation  no  debe  realizarse  mas  que  sobre 
el  globo  ocular  que  se  desvia;  pero  la  observation  demuestra  que 
la  unilateralidad  del  estrabismo  no  existe  mas  que  de  una  manera 
aparente,  y  que  la  bilateralidad,  cuando  no  es  espontanea  podemos 
provocarla  mandando  al  enfermo  cubrir  el  ojo  que  habitualmente 
fija,  lo  que  dara  origen  a  la  alternativa  de  la  desviacion  igual  para  los 
dos  ojos.  El  estrabismo  al  parecer  monocular,  dice  Onfray,  "se  debe 
a  que  uno  de  los  ojos  esta  forzosamente  dirigido  hacia  el  objeto  que  el 
individuo  quiere  ver;  pero  en  realidad  se  trata  de  un  espasmo  de  la 
convergencia,  funcion  eminentemente  binocular  por  su  misma  de- 
finition. Es,  pues,  logico  repartir  el  efecto  operatorio  sobre  los  dos 
ojos,  y  los  resultados  ban  demostrado  que  este  metodo,  no  rompiendo 
el  equilibrio  normal  binocular  en  los  movimientos  asociados,  facilita 
la  verdadera  cura." 

Algunos  ilustres  colegas  sostienen  nuestra  misma  opinion,  y  creen 
que  siendo  una  afeccion  binocular  se  la  debe  aplicar  un  tratamiento 
quinirgico  bilateral.  Consecuente  con  este  principio,  Pannas  prac- 
ticaba  la  doble  tenotomia  de  los  rectos  internes  y  externos,  segiin 
fuera  el  estrabismo  convergente  o  divergente,  y  Landolt,  el  doble 
avanzamiento  de  los  rectos  externos  o  internos,  segun  se  trate  de  una 
desviacion  estrdbica  interna  o  esterna. 

Si  echamos  una  rdpida  ojeada  sobre  las  opiniones  emitidas  por 
diversos  autores,  veremos  que  casi  todos  hablan  de  la  tenotomia,  del 
avance  capsulomuscular,  de  avance  muscular  unilateral  con  resec- 
tion, de  la  tenotomia  combinada  con  el  avance;  pero  ninguno  men- 
ciona  el  avance  bilateral  indicado  por  Landolt.  Es  mas,  asiin  despues 
de  haber  sido  preconizado  por  tan  eminente  colega,  apenas  si  lo  han 
practicado  aquellos  oculistas  que  mds  estrabismos  han  tratado 
quirurgicamente. 

En  efecto;  si  recorremos  el  capitulo  del  estrabismo  en  algunas 
publicaciones  modernas,  no  encontramos  en  ellas  la  recomendacion 
del  doble  avance  muscular  puro  y  simple,  hecha  por  Landolt. 

En  el  trabajo  de  Guedel  (1875)  sobre  la  patogenia  y  tratamiento 
del  estrabismo  despues  de  emitir  la  idea  de  que  el  verdadero  trata- 
miento del  estrabismo  es  el  quiriirgico,  dice  que  debemos  practicar 
la  tenotomia  sola  o  combinada  con  el  avance  del  musculo  antagonista, 
verdadera  panacea  de  la  correction  estrabica. 


Nuevo  Tratamiento  Quirurgico  del  Estrabismo  187 

Testut,  en  1881,  al  publicar  el  avanzamiento  del  tendon  en  el 
tratamiento  del  estrabismo,  manifiesta  que  hace  falta  repartir  entre 
los  dos  ojos  la  correction  de  la  desviacion,  pero  asociada  siempre  a  la 
tenotomia  del  recto  interne. 

En  la  publication  de  Bonnemaison  el  afio  1882  acerca  de  los  difer- 
entes  procedimientos  quinirgicos  para  el  estrabismo  monolateral 
excesivo,  tambien  indica  que  debe  practicarse  a  la  vez  el  avanzamiento 
del  recto  externo  y  la  tenotomia.  El  mismo  consejo  de  Lagrave  en 
1893  en  su  trabajo  de  contribution  al  estudio  del  tratamiento  qui- 
rurgico  del  estrabismo,  afirmando  que  la  base  del  tratamiento  radica 
precisamente  en  la  tenotomia. 

Mas  tarde,  tres  afios  despues,  en  1896,  Langle  en  nada  modifica  las 
opiniones  anteriores,  hasta  que  en  1906  Alberto  Delbarne  en  su 
"Estudio  clinico  sobre  el  tratamiento  operatorio  del  estrabismo  con- 
comitante  interne,"  indica  que  en  los  casos  de  gran  desviacion  debe 
intervenirse  en  los  dos  ojos,  practicando  el  doble  avance,  pero  asociado 
siempre  a  la  tenotomia,  como  venian  preconizando  los  demas  autores. 
Wecker  discute  sobre  las  tenotomias  simples,  o  las  tenotomias  con 
avanzamiento,  y  Fuchs  y  Kavel  no  hablan  del  doble  avance,  el  primero 
en  su  Tratado,  y  el  segundo  en  su  Manual  de  estrabismo.  Lo  mismo 
le  sucede  a  Bielchowsky  en  el  Tratado  reciente  de  Axenfeld  del  aiio 
1914.  Lagleyze  en  su  Tratado  del  estrabismo,  ano  1913,  aconseja  su 
acortamiento  muscular  especial,  sin  separar  el  miisculo  de  la  inserci6n, 
con  o  sin  tenotomia  del  antagonista. 

En  el  Congreso  de  la  Sociedad  Francesa  de  Oftalmologia  de  1893, 
Parinaud,  que  era  el  penente  para  el  tratamiento  del  estrabismo,  ni 
siquiera  menciona  el  doble  avanzamiento  muscular.  Morax  y 
Terrien  se  limitan  en  sus  modernos  Tratados,  a  citar  sencillamente  la 
operation.  Solamente  Landolt  vuelve  a  insistir,  despues  de  haber 
emitido  la  idea  del  doble  avance,  en  la  necesidad  de  que  la  operation 
se  generalice,  siendo  Benet  Onfray  el  que  mas  la  ha  dado  a  conocer 
en  su  magnifico  trabajo  sobre  el  estrabismo,  publicado  en  1907. 

Antes  de  esta  epoca,  en  1905,  Rochon  Duvigneaud  habia  empezado 
a  tratar  a  los  estrabicos  por  doble  avanzamiento  de  los  rectos  externos 
con  resultado  positive.  Los  exitos  que  consiguio,  le  hicieron  aplicar 
este  metodo  a  la  mayoria  de  los  estrabicos  que  opero  en  los  Hospitales 
de  Laennec  y  de  la  fundacion  Rothschild.  Su  discipulo  predilecto, 
Giraud,  en  su  notable  trabajo  sobre  el  doble  avanzamiento  muscular, 
al  hablar  de  su  maestro,  dice :  "  El  no  cree  que  toda  la  desviacion  pueda 
ser  corregida  por  el  doble  avance  mas  considerable  posible,  es  decir, 


188  B.  CASTRESANA 

con  reseccion  importante  del  tendon  muscular,"  pero  le  considera  un 
procedimiento  excelente. 

El  Dr.  Giraud,  consecuente  con  la  doctrina  de  su  maestro,  cree  que 
no  se  puede  desterrar  la  tenotomfa  actualmente  en  el  tratamiento  del 
estrabismo  si  bien  ha  de  reservarse  solo  para  ciertos  casos,  a  causa  de 
los  inconvenientes  que  tiene  para  que  se  realice  la  convergencia, 
debiendo  procurar  obtener  la  mayor  ventaja  con  el  doble  avanza- 
miento  muscular. 

En  cambio,  hay  otros  oculistas  como  Parinaud,  que  solamente 
cuando  el  resultado  obtenido  por  la  intervencion  unilateral  resulta 
incompleto,  es  cuando  interviene  en  el  ojo  fijador,  Lapersonne  en  las 
desviaciones  debiles  tampoco  interviene  mas  que  en  un  ojo,  y  es 
precise  que  la  desviacion  pase  de  mds  de  10°  para  que  practique  la 
intervenci6n  quirurgica  bilateralmente.  Por  mi  parte,  de  conformi- 
dad  con  la  opinion  de  Wecker,  creo  que  la  intervenci6n  unilateral 
podrfa  aplicarse  en  alguno  de  los  casos  de  estrabismo  que  el  llama 
incorrigibles,  en  los  que  no  podemos  esperar  mas  que  una  correccion 
de  su  deformidad,  pero  nunca  en  los  curables,  que  son  susceptibles 
de  recuperar  la  vision.  En  estos,  la  intervencion  a  mi  juicio  debe 
ser  siempre  bilateral,  respetando  al  sinergia  binocular. 

La  opinion  de  Rochon  Duvigneaud,  cuando  dice:  "En  aquellos 
casos  en  que  los  musculos  rectos  externos  muy  debiles  se  oponen  a 
los  rectos  internes  muy  fuertes,  el  doble  avanzamiento  muscular  por 
extenso  que  sea  resulta  insuficiente,  es  cierto;"  para  que  el  avance  de 
resultado,  tendremos  que  debilitar  los  internes.  Como  realizaremos 
esta  debilitacion?  Para  Rochon  Duvigneaud,  por  un  procedimiento 
ignorado  aun,  porque  la  tenotomia  es  una  operacion  brutal,  excesiva 
e  imposible  de  dosificar. 

En  efecto,  esta  operacion  que  todavia  la  practican  algunos  oculistas 
y  que  en  algunos  casos  muy  excepcionales  puede  llenar  alguna  indi- 
cacion,  podrfa  tener  su  apogeo  antiguamente,  cuando  se  admitia  la 
teoria  muscular  del  estrabismo,  pero  en  la  actualidad  no  debe  prac- 
ticarse  largo,  manu,  como  se  hace,  porque  al  debilitarse  el  musculo, 
no  solo  se  disminuye  la  abduccion  y  la  amplitud  de  convergencia, 
que  son  fact-ores  indispensables  para  restablecer  la  vision  binocular, 
sino  que  produce  alguna  vez  el  estrabismo  secundario. 

iSe  debe  abandonar  en  absolute  la  tenotomia?  Creo  que  la 
tenotomia  bilateral  no  debe  practicarse  nunca;  unicamente  la  de  un 
solo  lado  puedo  estar  justificada,  cuando  se  trata  de  un  estrabismo  con 
ambliopia  acentuada,  cuando  la  contractura  muy  marcada  del  mus- 


Nuevo  Tratamiento  Quirurgico  del  Estrabismo  189 

culo  se  acompaiio  de  cambios  de  estructura  con  peidida  de  su  elas- 
ticidad,  y  cuando  el  enfermo  es  de  edad  avanzado,  y  no  dispone  del 
tiempo  necesario  para  someterse  despues  de  la  operation  a  los  ejer- 
cicios  ortopticos  que  le  pudieran  reintegrar  a  la  vision  binocular. 
Aun  reuniendose  todas  estas  circunstancias,  se  debe  hacer  la  teno- 
tomfa  con  gran  prudencia  y  solo  en  las  desviaciones  estrabicas  muy 
debiles,  puesto  que  hemos  indicado  que  la  tenotomia  produce  una 
paresia  incurable,  que  dificulta  convergencia. 

Si  la  asociamos  al  avanzamiento,  constituye  la  operation  com- 
binada,  que  produce  un  enderezamiento  del  globo  ocular  mucho  mas 
acentuado.  Este  hecho  no  se  puede  negar,  porque  la  clinica  nos  lo 
confirma  algunas  veces;  pero  .de  admitirla,  a  creer,  como  dicen  los 
partidarios  de  la  tenotomia  combinada,  que  son  menos  marcados 
sus  inconvenientes,  porque  la  debilitation  del  musculo  es  limitada  por 
el  obstaculo  que  opone  el  avance  del  antagonista  a  la  exoftalmia, 
hay  una  gran  diferencia.  El  resultado  que  se  obtiene  con  algunas 
tenotomias  combinadas,  depende,  como  dice  Onfray,  del  musculo  que 
hemos  avanzado  en  modo  alguno  del  que  hayamos  tenotomizado. 

No  puedo  tampoco  admitir  la  opinion  de  Worth,  al  suponer  que  en 
los  grades  considerables  el  estrabismo,  no  se  puede  enderezar  el  globo 
ocular  con  los  avances  sin  producir  una  enoftalmia,  porque  tengo 
operados  de  estrabismos  muy  fuertes  con  el  doble  avanzamiento 
indirecto,  sin  que  se  haya  presentado  el  fantasma  enoftalmico.  Debo 
confesar  que  en  estos  enfermos  no  se  practice  el  doble  avance  sencillo, 
lo  asociamos  a  la  debilitation  del  musculo  antagonista,  en  la  forma 
que  indicare  al  hablar  de  la  tecnica  operatoria  que  ejecuto  general- 
mente,  cuando  opero  estrabismos  pronunciados.  Los  inconvenientes 
de  la  tenotomia  no  se  evitan  ni  disminuyen  en  lo  que  se  relaciona  con 
la  convergencia  asociandola  al  avanzamiento,  y  solo  debera  practicarse 
en  algunos  casos  muy  especiales  como  indicaba  anteriormente. 

La  operation  que  no  tiene  ninguno  de  los  inconvenientes  de  la 
tenotomfa  es  el  avance  muscular,  que  yo  llamo  indirecto,  que  no 
solamente  nos  corregira  el  estrabismo,  sino  que  muchas  veces  de- 
volvera  al  enfermo  estrabico  la  vision  binocular  perdida.  La  ob- 
jecci6n  que  se  ha  hecho  a  los  avances  diciendo  que  tiene  unos  efectos 
correctores  limitados,  puede  tener  algiin  valor,  cuando  se  trate  el 
avance  capsular,  o  muscular  unilateral,  que  es  insuficiente,  pero  la 
citada  objection  no  puede  hacerse  cuando  se  practique  el  avance 
bilateral,  con  resection  muscular  que  duplica  el  efecto  de  la  operation. 

En  el  caso  de  una  desviacion  muy  debil,  en  la  que  no  podamos  ob- 


190  B.  CASTRESANA 

tener  la  curacion  verdadera,  por  alteraciones  irremediables  en  el 
aparato  dioptrico,  el  avance  muscular  unilateral  puede  ser  algunas 
veces  suficiente ;  pero  si  queremos  baucar  la  vision  binocular,  la  cor- 
reccion  debe  ser  repartida  entre  los  dos  ojos.  La  aplicacion  de 
distintos  avances  para  cada  variedad  de  desviacion  no  la  podemos  ad- 
mi  tir  en  la  actualidad.  Es  inadmisible  establecer,  que  para  un  estra- 
bismo  inferior  a  10°,  se  practique  un  avance  capsular,  para  uno  de 
15  a  20  muscular,  y  si  pasa  de  25,  se  refuerce  con  la  reseccion  del 
musculo. 

Al  radicar  la  desviacion  estrabica,  al  parecer,  sobre  un  ojo  solo, 
lo  natural  es  que  la  operacion  recayese  solamente  sobre  el  ojo  desviado 
pero  la  unilateralidad  del  estrabismo,  repito  que  es  aparente,  la 
desviacion  estrabica  es  alterante,  lo  que  se  comprueba  mandando 
tapar  al  enfermo  el  ojo  que  fija,  como  dejo  indicado;  pues  entonces 
veremos  que  hay  desviaciones  iguales  en  los  dos  ojos.  Si  la  desvia- 
cion, por  lo  tanto,  es  bilateral,  el  efecto  operatorio  debera  repartirse 
entre  los  dos  ojos,  puesto  que  ambos  se  hallan  afectados. 

El  doble  avance  muscular  indirecto,  por  acortamiento  de  los 
musculos,  lo  practicaremos  en  el  estrabismo  convergente,  avanzando 
los  dos  rectos  externos  indirectamente,  como  describira  despues,  y 
en  el  divergente  los  rectos  internes.  Este  avance  no  disminuye  el 
campo  de  adduccion,  aumenta  el  de  abduccion  y  respeta  la  conver- 
gencia.  Debe  practicarse  siempre  bilateralmente,  si  perseguimos 
conseguir  la  vision  binocular  del  enfermo.  Con  el  avanzamiento 
muscular  doble  indirecto  por  reseccion  del  tendon,  que  le  injertaremos 
despues  de  acortado  en  su  primitive  punto  de  insercion,  aumentamos 
de  una  manera  considerable  la  potencia  de  enderezamiento  del 
avance  muscular,  y  conservaremos  siempre  la  convergencia.  Las 
excursiones  nasales  no  pierden  nada,  las  tenporales  se  normalizan, 
y  los  ojos  se  mueven  correctamente.  Muchas  veces  se  obtiene  la 
vision  binocular,  y  una  amplitud  de  convergencia  normal. 

Al  ocuparse  el  Dr.  Rochon  Duvigneaud  del  doble  avanzamiento, 
no  pretende  corregir  todas  las  desviaciones  por  ,esta  operacion. 
Cuando  los  rectos  internes  son  muy  fuertes  en  el  estrabismo  conver- 
gente, y  los  rectos  externos  muy  debiles,  dice  que  sera  precise  ademas 
de  los  avances,  disminuir  la  energia  potencial  de  los  musculos  rectos 
internos,  por  algiin  medio  especial,  que  quizas  pudiere  ser  seccionado 
alguna  fibra  muscular  en  todo  el  ancho  del  musculo,  porque  la  teno- 
tomia  es  una  operacion  que  no  se  puede  dosificar. 

En  el  estrabismo  divergente  lo  mismo  que  el  convergente,  la  accion 


Nuevo  Tratamiento  Quirurgico  del  Estrabismo  191 

correctora  del  doble  avance  indirecto  es  buena  y  podemos  aumentarla 
resecando  una  portion  mayor  o  menor  del  musculo,  segun  nos  con- 
venga. 

La  abduction  no  disminuye  con  la  operation  y  en  cambio  conse- 
guimos  que  aumente  notablemente  la  adduction.  En  este  variedad 
de  estrabismo  el  campo  de  adducci6n  est£  limitado  en  los  dos  ojos  y 
mejora  con  el  avance  bilateral. 

A  los  rectos  internes  les  proporciona  una  contraction  suficiente  y 
paralena  para  poder  realizar  la  vision  binocular,  sobre  todo  en  aquellos 
estrabicos  que  tienen  la  facultad  de  fusion  muy  desarrollada.  Con 
los  avances,  por  lo  tanto,  conseguiremos  una  correction  estetica  y 
funcional  a  la  vez,  que  es  precisamente  nuestro  bello  ideal. 

Claro  esta  que  no  se  pueden  corregir  los  estrabismos  muy  pro- 
nunciados  con  solo  el  avance  bilateral  indirecto,  pero  si  lo  asociamos 
a  la  debilitation  del  musculo  antagonista,  en  la  forma  que  indicare, 
el  problema  de  la  correction  del  estrabismo  queda  resuelto  para  todos 
los  casos  que  se  nos  puedan  presentar. 

La  tecnica  operatoria  que  practicamos  en  el  avance  bilateral  in- 
directo con  debilitation  del  musculo  antagonista,  se  diferencia  de  la 
que  emplean  otros  eminentes  colegas,  en  detalles,  tan  importantes, 
que  la  podemos  considerar  como  nueva,  aunque  se  nos  diga  parodiando 
a  Salomon  jque  nibil  novum  sub  sole.  Es  cierto  que  nada  puede  con- 
siderarse  como  nuevo,  pero  si  a  un  procedimiento  operatorio  se  le 
modifica  en  su  principio  fundamental,  y  ademds  se  le  anade  un  acto 
quirurgico  que  viene  a  complementarle,  y  corregir  las  deficiencias 
que  tiene,  creo  nos  podemos  considerar  autorizados  para  calificarle 
como  nuevo. 

iComo  se  debe  realizar  el  procedimiento  operatorio  ideal  del  estra- 
bismo pronunciado?  En  la  forma  que  vamos  a  describir: 

Se  hace  anestesia  local  mediante  inyecciones  subconjunti vales  y 
musculares  con  solution  en  suero  fisiologico  de  novocaina  y  adrenalina 
que  es  suficiente,  o  anestesia  general  con  cloroformo  que  es  la  que 
prefieren  casi  todos  los  enfermos  para  evitar  el  dolor  por  complete. 
Anestesiado  el  paciente  en  cualquiera  de  las  dos  formas,  se  desinfecta 
el  campo  operatorio,  por  medio  de  repetidos  lavados  con  la  solution 
acuosa  al  4  por  100  de  dcido  borico,  y  se  empieza  la  operation  de- 
bilitando  los  musculos  rectos  internos  en  el  estrabismo  convergente, 
para  despues  practicar  el  doble  avanzamiento  indirecto,  o  viceversa, 
se  debilitan  los  externos  y  se  avanzan  los  internos  cuando  se  trata  de 
un  estrabismo  divergente. 


192  B.  CASTRESANA 

Para  debilitar  el  musculo  que  es  el  punto  mas  original  e  impor- 
tante  de  mi  intervention,  se  empieza  por  aislar  su  tendon  en  la  forma 
que  lo  hacemos  cuando  se  desea  separar  lo  del  globo  ocular.  Colocado 
el  separador  palpebral,  se  coje  con  la  pinza  la  conjuntiva  a  unos 
cuantos  milimetros  del  limbo  esclerocorneal.  El  pliegue  que  hemos 
levantado  de  la  membrana  conjuntival  se  escinde  de  un  tijeretazo,  y 
nos  queda  de  este  modo  abierto  en  ojal  en  la  conjuntiva,  de  unos  cinco 
o  seis  milimetros  de  extension  aproximadamente. 

Despue"s,  con  ayuda  de  las  tijeras  disecamos  los  labios  del  ojal, 
levantando  la  conjuntiva  en  todas  direcciones  hasta  poner  al  des- 
cubierto  la  inserccion  tendinosa  del  musculo,  que  estard  cubierta 
por  la  capsula.  Cogemos  a  esta  con  la  pinza  al  nivel  del  borde 
superior  del  tendon,  y  con  la  punta  de  la  tijera  la  incindimos  pro- 
duciendo  una  pequena  abertura  por  donde  se  introduce  el  gancho  de 
estrabismo.  La  punta  de  este  instrumento  dirigida  hacia  atrds 
rasando  sobre  la  esclerotica  pada  por  debajo  del  musculo,  y  se  pre- 
senta  cubierta  por  la  capsula  al  nivel  del  borde  inferior  del  tendon 
muscular. 

Se  da  un  corte  con  la  tijera  en  la  capsula  y  queda  libre  la  punta  del 
gancho.  Se  introduce  otro  por  la  abertura  practicada,  que  sustituye 
al  primero  y  que  camina  en  sentido  opuesto,  con  el  fin  de  coger  el 
tendon  en  su  totalidad,  y  una  vez  conseguido,  se  levanta  con  fuerza 
sujetandolo  con  la  mano  izquierda.  Colocado  el  tendon  en  esta 
forma,  con  la  tijera  o  un  bisturi,  se  dan  dos  cortes  en  direction  vertical, 
a  unos  dos  o  tres  milimetros  por  detras  de  la  inserccion  que  tiene  el 
musculo  con  la  esclerotica  y  eri  una  extension  variable,  segun  quera- 
mos  debilitar  mas  o  menos  la  potencia  muscular.  Los  citados  cortes 
seran  practicados  en  las  partes  intermedias,  sin  cortar  nunca  las 
fibras  correspondientes  a  los  bordes  musculares,  superior  e  inferior, 
ni  tampoco  las  correspondientes  a  la  parte  central,  con  el  fin  de  que 
no  se  modifique  el  centre  del  rotation  del  globo  ocular.  Cortada 
en  esta  forma  la  cantidad  del  musculo  que  nos  convenga,  se  saca  el 
gancho  que  lo  sujetaba  y  se  reunen  los  bordes  cruentos  de  la  con- 
juntiva, mediante  un  punto  de  sutura,  pasando  inmediatamente 
despues  a  practicar  el  avance  bilateral  indirecto  de  los  miisculos 
debilitados. 

Se  coloca  el  blefarostato  y  se  desinfecta  el  ojo  en  igual  forma  que 
lo  hicimos  para  la  debilitation  del  musculo.  Despues  un  ayudante 
por  medio  de  una  pinza  para  fijar,  colocada  cerca  del  limbo,  sostiene 
por  dentro  del  globo  ocular,  mientras  que  el  operador  coge  con  la 


Nuevo  Tratamiento  Quirurgico  del  Estrabismo  193 

pinza  un  pliegue  de  la  conjunctiva,  a  unos  cuatro  milimetros  del 
limbo  esclerocorneal  y  de  un  tijeretazo  lo  escinde,  resecando  una 
pequena  porcion  de  conjuntiva  en  forma  de  media  luna  de  concavidad 
corneal,  que  deja  al  descubierto  la  insercion  muscular  en  la  esclerotica. 
Descubierta  la  insercion  del  tendon,  se  coge  la  capsula  en  el  borde  su- 
perior del  musculo,  y  con  la  punta  de  la  tijera  se  practica  en  ella  una 
pequena  abertura,  por  la  que  se  introduce  un  gancho  fino  de  estra- 
bismo,  que  llevandolo  al  ras  de  la  esclerotica  por  debajo  del  musculo, 
viene  a  levantar  en  su  borde  inferior  la  capsula  que  se  desprende  de 
un  tijeretazo. 

Cogido  el  tendon  muscular  en  toda  su  extension  con  el  gancho,  se 
diseca  el  musculo  con  tijeras  curvas  de  punta  roma,  aislandole  de  la 
conjuntiva  de  la  capsula  y  de  tejido  episcleral.  Separado  completa- 
mente,  se  levanta  con  la  ayuda  del  gancho  de  estrabismo,  para  su- 
jetarle  con  la  pinza  de  Prince,  a  una  distancia  de  su  insercion  tendi- 
nosa  proporcional  al  grado  de  estrabismo.  Colocado  el  musculo  en 
esta  situacion,  se  secciona  al  ras  de  la  pinza,  por  delante  de  ella, 
quedandonos  un  trozo  suelto  de  musculo  mayor  o  menor  unido  a  la 
escler6tica  por  su  insercion  anterior,  que  serd  el  que  resequemos 
despues  de  colocar  la  sutura  en  rombo  que  describiremos  mds  tarde. 

El  trozo  de  musculo  que  resecamos,  es  mas  o  menos  extenso,  segun 
sea  mayor  o  menor  la  desviacion  estrabica,  calculando  su  extension 
con  bastante  exactitud  en  la  actualidad,  a  consecuencia  de  los  estudios 
comparatives  que  hemos  hecho  en  la  clinica  al  ver  los  efectos  que 
producen  las  distintas  cantidades  de  musculo  resecado. 

Desde  luego  podemos  decir  que  no  se  pueden  dar  dosis  de  resecci6n 
con  exactitud  matematica,  por  cada  grado  de  desviacion,  pero  pode- 
mos asegurar,  que  no  se  deben  tener  las  amplias  resecciones,  y  menos 
si  se  aplica  este  calificativo  a  la  reseccion  de  4  6  5  milimetros  como 
quiere  Landolt.  En  los  estrabismos  muy  pronunciados  he  llegado  yo 
a  resecar  hasta  12  y  15  milimetros  con  une  resultado  muy  satisfactorio. 

El  Dr.  Jenaro  Gonzalez,  uno  de  los  oculistas  espanoles  que  ha 
estudiado  con  mds  entusiasmo  el  problema  quinirgico  del  estrabismo, 
en  su  comunicacion  a  la  Academia  Quirurgica  el  afio  1915,  acerca  de 
modificaciones  quirurgicas  al  procedimiento  operatorio  de  reseccion 
tendinosa  Schweigger,  establece  un  cdlculo  matematico  para  precisar 
con  exactitud  la  cantidad  de  tendon  que  hemos  de  resecar,  conforme 
el  angulo  de  desviacion  estrabica.  Segiin  sus  calculos  matematicos, 
la  cantidad  de  tendon  que  podemos  resecar  es  de  2  milimetros  por 
cada  10°  de  desviacion.  En  la  clinica  esta  cantidad  resulta  algo 
13 


194  B.  CASTRESANA 

insuficiente,  y  el  resultado  de  su  modificaci6n  al  procedimiento 
Schweigger  no  lo  cree  muy  seguro  cuando  dice:  "En  algunos  casos 
puede  completarse  la  operacion  alongando  el  miisculo  antagonista, 
segiin  el  metodo  de  Verhoeff." 

Es  dificil  responder  a  esta  cuestion  con  una  cifra  exacta,  dice  La- 
gleyze,  al  hablar  del  acortamiento  muscular,  porque  la  solucion  de- 
pende  de  causas  desconocidas  que  pueden  cambiar  segiin  las  cir- 
cunstancias.  Entre  ellas  las  resistencias  de  los  diversos  tejidos,  que 
varian  de  un  sujeto  a  otro,  en  virtud  de  la  edad,  de  la  antigiiedad  del 
estrabismo,  de  las  diferencias  de  la  estructura  de  los  miisculos,  o  en 
las  adherencias  anormales  que  han  podido  realizarse  en  el  transcurso 
del  tiempo,  del  conocimiento  exacto  de  la  resultante  de  fuerzas,  que 
acentuan  sobre  el  ojo  en  distinta  direccion,  al  ejecutar  sus  movi- 
mientos,  y  de  causas  funcionales  o  anatomicas  imposibles  de  resolver. 
De  este  modo,  puede  explicarse  como  en  dos  estrabismos  de  un  grado 
igual  de  desviacion,  una  misma  cantidad  de  miisculo  resecado  puede 
dar  un  resultado  diferente.  No  obstante,  creo  se  puede  calcular 
aproximadamente  una  reseccion  muscular  de  dos  y  medio  milimetros 
por  cada  diez  grados,  por  lo  que  he  podido  observar  en  la  clfnica. 

El  mismo  Dr.  Gonzalez  expresa,  que  la  solucion  matemdtica  apli- 
cable  a  los  tejidos  tiene  su  limite,  porque  en  ellos  inter vienen  ciertos 
factores  que  no  es  posible  solucionar  con  niimeros.  Los  rmisculos, 
dice  Onfray,  no  son  cintas  inertes,  sino  tejidos  que  tienen  una  con- 
tractilidad  propia,  sometida  a  la  accion  mas  o  menos  intensa  de  la 
energia  nerviosa,  y  aunque  pudieramos  calcular  con  exactitud  mate- 
mdtica  la  mudanza  de  insercion  del  miisculo  resecado,  aiin  en  este 
caso,  nos  serla  imposible  precisar  exactamente  la  cantidad  de  tendon 
que  debemos  resecar,  porque  la  prdctica  clinica  demuestra  que  tal 
precision  es  imposible. 

El  trozo  de  tendon  libre,  separado  de  la  pinza  de  Prince  al  ser 
cortado  el  musculo  que  permanece  unido  a  la  esclerotica  en  su  parte 
anterior,  nos  sirve  de  punto  de  apoyo  para  sujetar  con  la  pinza 
el  globo  ocular,  al  colocar  la  sutura  en  rombo,  que  es  otro  de  los 
puntos  diferenciales  importantes  de  este  procedimiento. 

La  sutura  en  rombo  la  componen  tres  puntos,  uno  central  y  dos 
laterales.  El  primero  sigue  el  didmetro  horizontal.  Comienza 
penetrando  desde  cerca  de  la  cornea  por  debajo  de  la  conjuntiva  y 
de  algunas  fibras  escleroticales,  pasa  por  debajo  de  la  inserci6n  del 
tendon  por  donde  sale,  penetra  de  nuevo  en  el  espesor  de  las  fibras 
de  la  esclerotica  por  donde  camina  en  una  extension  de  unos  dos  mili- 


Nuevo  Tratamiento  Quirurgico  del  Estrabismo  195 

metres,  y  finalmente,  pasando  de  dentro  a  fuera  por  detras  de  la 
pinza  de  Prince,  el  miisculo,  la  cdpusla  y  la  conjuntiva,  viene  a  salir 
cerca  del  angulo  palpebral  externo. 

Los  otros  dos  puntos  laterales  de  la  sutura  superior  e  inferior,  em- 
piezan  a  unos  dos  milimetros  del  central  y  atraviezan  los  mismos 
tejidos.  Al  salir  por  debajo  de  la  insercion  tendinosa  del  trozo  de 
miisculo  que  hemos  cortado  se  desvian  hacia  el  ecuador  del  globo 
ocular,  para  atravesar  en  este  punto  algunas  fibras  escleroticales. 
Despues  de  haberlas  atravesado  convergen  en  direction  al  central  a 
pasando  por  la  parte  interna  del  miisculo,  capsula  y  conjuntiva, 
viene  a  terminar  en  la  misma  region  del  punto  central.  Estos  puntos 
de  sutura  pueden  oblicuarse  mas  o  menos,  hacia  arriba  o  hacia  abajo, 
si  el  estrabismo  es  algo  superior  o  inferior. 

Constituida  la  sutura  en  esta  forma  limita  una  superficie  romboidal 
con  un  diametro  anteroposterior  mayor  que  el  vertical.  Actiian  en 
ella  tres  fuerzas  sobre  la  linea  que  une  los  tres  puntos  de  intersection 
del  miisculo  con  la  esclerotica,  produciendose  asi  una  composition  de 
fuerzas  cuya  resultante  dependera  del  valor  de  cada  una  de  ellas, 
o  sea  de  la  potencia  de  cada  una  de  estas  cuerdas.  Su  colocacion 
especial  da  lugar  a  fuertes  adherencias  escleroticas,  que  impiden  con 
el  tiempo  vuelva  a  presentarse  de  nuevo  la  desviacion  ocular,  como 
ocurre  con  las  suturas  que  se  practican  en  otros  procedimientos, 
proque  no  debemos  olvidar  que  la  colocacion  de  los  puntos  es  uno  de 
los  factores  principales  de  la  operation. 

Colocados  en  la  forma  indicada  los  puntos  de  sutura,  se  suelta  la 
pinza  de  Prince,  y  teniendo  los  hilos  de  seda  algo  tensos  un  ayudante, 
se  secciona  la  porci6n  resecada  del  miisculo  al  ras  de  su  insercion 
tendinosa.  Despues,  aproximando  el  ayudante  con  las  pinzas  los 
bordes  de  la  incision  de  la  conjuntiva,  se  hace  el  anudamiento  de  los 
puntos,  comenzando  por  el  del  centre.  Al  colocar  estos,  se  trae  el 
borde  cruento  del  miisculo  resecado  a  injertarle  en  el  punto  de  la 
esclerotica,  donde  se  insertaba  el  tendon,  provocando,  por  lo  tanto, 
un  avanzamiento  indirecto  del  musculo,  puesto  que  una  parte  mas 
posterior  del  mismo  viene  a  colocarse  en  una  region  mds  anterior  de 
la  esclerotica,  pero  sin  traspasar  los  limites  de  la  primitiva  insercion 
tendinosa,  con  el  fin  no  se  rompa  el  equilibrio  muscular.  Si  el  estra- 
bismo es  directo,  se  aprietan  igual  todos  los  puntos,  pero  si  es  ligera- 
mente  oblicuo,  pondremos  un  poco  mds  tenso  el  lateral  correspon- 
diente. 

Hecho  esto,  se  fijan  los  extremes  de  la  seda  con  un  esparadrapo  a  la 


196  B.  CASTRESANA 

parte  externa,  se  instilan  en  ambos  ojos  unas  got  as  de  atropina  con 
el  fin  de  paralizar  la  acomodacion,  y  se  coloca  un  vendaje  binocular. 
Los  grabados  que  publicamos  hacen  que  se  comprendan  facilmente 
los  distintos  tiempos  de  la  nueva  tecnica  operatoria  que  empleamos 
para  corregir  el  estrabismo. 

Si  hemos  seguido  todas  las  reglas  de  la  asepsia,  no  hay  temos  a  la 
infeccion,  y,  por  lo  tanto,  no  es  necesario  levantar  el  vendaje  hasta 
pasadas  las  cuarenta  y  ocho  opras  despue"s  de  la  operacion.  Al 
levantar  el  vendaje  lavaremos  bien  ambos  ojos  con  la  solucion  borica  e 
instilaremos  nuevamente  atropina.  Estas  curas  se  repetiran  cada  dos 
dias,  y  al  octavo  se  podran  quitar  los  puntos  de  sutura,  dejando  un 
vendaje  monocular  en  el  ojo  que  no  se  desviaba,  y  en  el  estrabico  una 
pantalla  colocada  mas  hacia  el  lado  que  tuvo  el  estrabismo,  para  que 
el  enfermo  mire  por  el  lado  contrario.  Se  sigue  instilando  atropina 
hasta  que  desaparezca  por  complete  todo  fenomeno  de  reaccion 
operatoria,  y  llegado  este  momento  se  suprime  el  midriasico  para 
que  vuelvan  a  contraerse  las  pupilas,  conseguido  lo  cual  se  hace  la 
direccion  del  defecto  de  refraccion  que  hubiere  en  los  ojos  y  se  da 
comienzo  a  la  gimnasia  de  convergencia  y  acomodacion,  que  ejecutara 
el  enfermo  por  espacio  de  mucho  tiempo,  empleando  los  medios 
ortopticos,  con  el  fin  de  conseguir  la  vision  binocular,  que  es  la  ver- 
dadera  curacion  del  estrabismo. 

Desde  el  afto  1915,  que  empece  a  practicar  esta  tecnica  operatoria, 
hasta  la  epoca  presente,  la  he  modificado  en  algunos  detalles  para 
corregir  pequenas  deficiencias  que  pude  observar  tenia  en  mis  primeras 
intervenciones.  En  la  description  que  dejo  expuesta,  se  incluyen 
hasta  los  datos  m&s  insignificantes  de  las  modificaciones  hechas  en 
el  procedimiento  operatorio  hasta  el  momento  actual.  Creo  se  puede 
decir  que  he  llegado  a  su  perfeccionamiento  complete,  si  tenemos 
en  cuenta  los  resultados  altamente  satisfactorios  que  obtengo  con  su 
empleo. 

El  numero  de  enfermos  que  he  sometido  a  esta  intervencion  qui- 
rurgica  desde  el  afto  1915  al  1919  pasan  de  100. 

iComo  podria  evitarse  la  intervention  quirurgica  en  el  estrabismo? 
En  muchos  casos  preViniendo  el  desarrollo  de  la  enfermedad,  para  lo 
que  es  necesario  tratarlo  convenientemente  cuando  se  inicia,  porque 
hemos  de  advertir  que  el  tratamiento  quirurgico  no  produce  siempre 
la  curacion  verdadera  del  estrabismo.  Es,  por  lo  tanto,  de  un  valor 
terape"utico  inferior  a  los  medios  6pticos  y  ortopticos. 

Los  primeros  corrigen  los  vicios  de  refraccion  del  aparato  dioptrico, 


Nuevo  Tratamiento  Quirurgico  del  Estrabismo  197 

o  lo  que  es  lo  mismo,  evitan  las  causas  que  predisponen  al  estrabismo, 
y  los  segundos  educando  la  vision  binocular  contribuyen  poderosa- 
mente  a  remediar  el  defecto  de  la  facultad  de  fusion,  de  donde 
resulta,  en  realidad,  que  el  enderezamiento  ocular  mediante  la 
intervencion  quirurgica,  no  es  mas  que  un  auxiliar  de  los  medios 
funcionales  cuando  buscaraos  la  curacion  verdadera  del  estrabismo. 

Si  el  estrabismo  es  un  vicio  de  desarrollo  de  la  vision  binocular, 
que  se  favorece  por  causas  locales,  se  comprende  facilmente  que  el 
empleo  de  los  llamados  medios  funcionales  debe  establecerse  desde 
el  momento  que  se  inicia  el  estrabismo  en  la  nifiez.  Es  precise 
educar  a  los  padres  para  que  salgan  de  su  indiferencia  in  justifiable, 
esperando  una  curacion  expontanea  que  nunca  llega,  y  es  necesario 
convencer  a  las  madres  de  que  es  imprescindible  hacer  cuanto  sea 
posible  para  que  los  ninos  lleven  cristales  correctores  de  su  vicio  de 
refraccion,  aun  cuando  sean  antiesteticos. 

Si  los  padres  abandonan  a  sus  hijos  en  la  nifiez,  las  modificaciones 
que  se  realizan  en  el  aparato  de  la  vision  binocular  son  cada  vez  mas 
profundas,  y  cuando  son  ya  crecidos,  la  correccion  optica  y  el 
tratamiento  ortoptico  daran  un  resultado  poco  satisfactorio,  teniendo 
necesidad  de  asociarlo  al  tratamiento  quiriirgico. 

La  intervencion  operatoria  no  esta  justificada  en  los  ninos  pequenos 
de  dos  a  siete  anos.  En  esta  edad  limitaremos  nuestro  tratamiento 
a  una  correccion  optica  bien  hecha,  a  la  atropinacion  del  empleo  de 
los  ejercicios  ortopticos  desde  el  momento  que  lo  permita  la  inteli- 
gencia  del  nifio,  con  lo  que  se  consigue  muchas  veces  desarrollar  la 
facultad  de  la  fusion,  manteniendo  el  equilibrio  monocular.  Estos 
ejercicios  los  hara  el  niiio  lo  antes  posible  con  el  amblioscopio  Worth, 
instrumento  el  mas  aproposito  para  el  nifio  porque  le  divierte,  al 
mismo  tiempo  que  le  hace  desarrollar  el  sentido  de  al  fusion. 

Cuando  los  padres  han  abandonado  al  enfermito,  en  los  primero 
tiempos  de  presentarse  la  enfermedad,  y  el  estrabismo  se  ha  hecho 
permanente  con  marcada  ambliopia  del  ojo  desviado,  es  precise 
mejorar  la  agudeza  visual  de  este,  corrigiendo  la  anatropia  atro- 
pinizando  el  ojo  fijador.  Desde  el  momento  que  el  ojo  ambliope 
trabaja  diariamente,  mejora  su  agudeza  de  una  manera  rdpida,  y  en 
poco  tiempo  nos  encontramos  en  condiciones  de  practicar  con  fruto 
ejercicios  de  vision  simultdnea  y  binocular,  con  el  amblioscopo  y  el 
esteroscopo. 

El  mismo  adolescente,  que  sabe  leer,  debe  someterse  a  los  medios 
funcionales  que  dejo  indicados  y  ademds  hard  diariamente  sesiones 


198  B.  CASTRESANA 

de  vision  binocular  ayudado  del  diploscopo  de  Remy,  alternando  los 
ejercicios  eteroscopicos  con  cartones  divertidos.  El  uso  del  estero- 
scopo,  dice  Onfray,  es  muy  util,  despues  de  hacer  uso  del  diploscopo 
"para  relajar  activamente  la  convergencia,  fortificar  el  sentido  de  la 
fusion  y  producir  la  sensacion  de  relieve";  los  ejercicios  ortopticos 
deberdn  terminarse  con  sesiones  de  vision  binocular  sin  instrumento, 
mediante  la  lectura  comprobada.  El  estrabico  debe  trabajar  con- 
stantemente  por  extender  su  campo  de  vision  binocular,  y  forti- 
ficar sin  descanso  la  aptitud  adquirida  de  fusionar  la  doble  imagen, 
para  lo  que  es  precise  que  ejerzamos  sobre  el  una  especie  de  sugestion 
y  no  abandone  el  tratamiento. 

Aiin  cuando  no  llegamos  al  enderezamiento  del  globo  ocular,  la 
aptitud  a  la  fusion  de  las  imagenes  que  hayamos  conseguido  por 
medio  de  los  ejercicios  funcionales,  contribuird  poderosamente  a  la 
curacion  verdadera  del  estrabismo  cuando  tengamos  necesidad  de 
intervenir  quinirgicamente. 

Si  a  pesar  de  haber  empleado  todos  los  medios  llamados  funcionales, 
el  nino  llega  a  los  doce  o  catorce  afios  sin  haber  conseguido  la  vision 
mas  que  en  ciertas  posiciones  de  la  mirada  y  sin  haber  corregido  mas 
que  de  una  manera  incompleta  su  desviacion,  debemos  aconsejarle  la 
intervencion  quirurgica,  que  aplicaremos  sobre  los  dos  ojos,  con  el 
fin  de  obtener  su  curacion  verdadera. 

La  tecnica  quirurgica  que  apliquemos  ha  de  variar  necesariamente 
segun  el  grado  de  desviacion  estrabica  que  tenga  el  enfermo.  Si 
esta  es  debil,  inferior  a  14°,  es  suficiente  el  doble  avance  muscular 
indirecto  con  pequena  reseccion  tendinosa  y  la  sutura  en  rombo,  para 
que  podamos  conseguir  facilmente  la  correction  del  estrabismo. 
Cuando  el  dngulo  de  desviacion  alcanza  de  18  a  20°,  serd  precise 
ademds  del  avance,  la  reseccion  muscular  mas  extensa  en  la  forma 
indicada  anteriormente,  y  por  ultimo,  para  las  desviaciones  mas 
elevadas  hasta  cuarenta  y  tantos  grados,  asociaremos  al  avance  y 
reseccion,  la  debilitation  de  los  musculos  antagonistas,  rectos, 
internes  o  externos,  segun  sea  el  estrabismo  convergente  o  divergente, 
practicando  en  todos  los  casos  la  sutura  romboidal. 

No  olvidaremos  en  la  tecnica  operatoria  un  detalle  que,  a  mi  juicio, 
tiene  mucha  importancia;  me  refiero  a  que  no  debemos  quietar  los 
hilos  de  sutura  mientras  no  pasen  ocho  dias  despue's  de  la  intervencion 
para  que  las  adherencias  de  los  tejidos  puestos  en  contacto  durante  el 
acto  operatorio  se  consoliden  completamente  antes  de  separar  los 
hilos.  Es  necesario  tambien  recordar  el  beneficio  que  reporta  la 


Nuevo  Tratamiento  Quirurgico  del  Estrabismo  199 

atropinizacion  de  los  dos  ojos  para  relajar  la  convergencia,  el  empleo 
inmediato  de  los  ejercicios  ortopticos,  mediante  el  diploscopo,  el 
esteroscopo  y  los  ejercicios  de  vision  binocular  sin  instrumentos,  en 
el  ultimo  perfodo.  Mediante  estos  recursos,  podemos  en  muchos 
casos,  si  el  enfermo  dispone  de  tiempo  y  paciencia,  llegar  a  la  ver- 
dadera  curacion  del  estrabisrno. 

Decimos  al  hablar  de  la  intervencion  quiriirgica,  que  debe  aplicarse 
sobre  los  dos  ojos,  y  asi  debe  ser  en  efecto,  cuando  buscamos  la  cura- 
cion verdadera;  pero  en  aquellos  casos  en  los  que  el  enfermo  no  desee 
recobrar  su  vision  binocular,  o  se  trate  de  una  muchacha  joven,  que 
bajo  ningun  concepto  ha  de  llevar  puestos  sus  vidrios  correctores, 
para  no  afear  su  belleza,  estamos  autorizados  a  practicar  una  inter- 
vencion monocular  y  hasta  la  tenotomia  prudente,  operacion  que 
hemos  de  rechazar  en  la  mayoria  de  los  casos,  por  las  razones  que 
hemos  consignado  al  hablar  de  la  te"cnica  quimrgica  del  estrabismo. 

De  cuanto  llevo  expuesto  se  deducen  los  siguientes  corolarios : 

El  estudio  de  la  tecnica  operatoria  del  estrabismo,  es  uno  de  los 
capitulos  de  nuestra  especialidad  que  menos  ha  progresado  en  Espana, 
hasta  la  epoca  actual,  lo  que  se  debe  a  la  escasez  de  material  clinico 
humane  para  iritervenir  quinirgicamente,  y  no  al  prejuicio  religiose, 
como  opina  algiin  ilustre  colega  extranjero. 

Las  intervenciones  quirurgicas  del  estrabismo  son  diversas,  segun 
dejamos  consignado.  La  mayor  parte  de  los  autores  emplean  una 
tecnica  que  se  diferencia  de  la  general,  en  detalles  mas  o  menos  im- 
portantes,  sin  que  tengamos  hasta  la  fecha  una  que  sea  aceptada  como 
procedimiento  ideal  por  todos  los  operadores. 

La  tenotomia,  el  acortamiento  muscular,  el  avanzamiento  muscu- 
lar, el  avance  capsular,  capsulomuscular,  el  muscular  simple,  o  con 
reseccion  de  mayor  o  menor  parte  del  rmisculo,  y  la  miectomia,  son 
los  distintos  procedimientos  que  aisladamente,  o  combinados  con  la 
tenotomia  del  musculo  antagonista,  se  vienen  aconsejando  indistinta- 
mente  segun  la  variedad  y  mayor  o  menor  grado  de  desviacion  que 
tenga  el  enfermo  estrabico,  lo  que  demuestra  la  falta  de  un  procedi- 
miento quiriirgico  que  pueda  aplicarse  con  las  variantes  consiguientes, 
en  todos  los  casos  de  estrabismo  que  se  nos  presenten. 

La  tenotomia,  operacion  indosificable,  de  efectos  variables,  in- 
seguros  y  perniciosos  siempre  para  la  convergencia,  debe  abandonarse 
casi  por  complete,  practicandose  solamente  en  algun  caso  muy  ex- 
cepcional,  porque  puede  producir  a  la  larga  fecha  la  retraccion  del 


200  B.  CASTRESANA 

pliegue  semilunar  de  la  caruncula,  desviaciones  secundarias,  paresia 
muscular  y  dificultades  en  la  vision  binocular. 

El  avanzamiento  muscular,  o  el  acortamiento  del  miisculo,  que 
aconsejan  practicar  algunos  autores  unilateralmente,  es  insunciente 
en  la  mayorfa  de  los  estrdbicos,  si  no  se  combina  con  la  tenotomfa, 
en  cuyo  caso  la  intervention  adolece  de  los  defectos  de  esta  operacion. 
Lo  mismo  ocurre  con  los  desbridamientos  capsulares,  el  avanza- 
miento muscular  sencillo  monocular  asociado  con  la  reseccion  del 
mtisculo. 

Son  procedimientos  operatorios  insuficientes  por  si  solos  para 
corregir  los  diversos  grades  de  una  desviacion  estrabica  pronunciada. 

El  doble  avanzamiento  muscular  sencillo  indirecto  o  con  resecci6n 
de  cierta  cantidad  de  miisculo,  siempre  asociado  a  la  sutura  romboidal 
y  combinado  con  la  debilitation  de  los  musculos  antagonistas  cuando 
la  desviacion  estrdbica  es  pronunciada,  me  parece  el  tratamiento 
quirurgico  ideal  del  estrabismo  en  la  actualidad. 

Las  desviaciones  estrabicas  de  poca  intensidad  se  corrigen  con  el 
doble  avanzamiento  sencillo  indirecto,  pequena  reseccion  tendinosa 
y  la  sutura  en  forma  romboidal.  En  los  grades  fuertes  de  estrabismo 
es  preciso  afiadin  ademas,  la  reseccion  muscular  en  mayor  o  menor 
extension,  y  la  debilitation  de  los  musculos  antagonistas. 

Con  este  tratamiento  quirurgico,  la  correccion  estetica,  conseguida 
desde  el  primer  momento,  persiste  y  mejora  en  el  porvenir  al  restable- 
cerse  el  equilibrio  muscular,  lo  que  no  ocurre  generalmente  con  otros 
procedimientos. 

Es  la  operacion  mas  racional  para  que  se  normalicen  paulatinamente 
las  excursiones  del  globo  ocular  y  para  que  la  vision  binocular  se 
restablezca  en  todos  aquellos  casos  que  lo  permita  su  agudeza  visual. 

Los  operados  deben  someterse  a  la  correccion  6ptica  y  al  trata- 
miento ort6ptico  consecutive,  como  en  los  demds  procedimientos 
operatorios. 

El  doble  avance  muscular  indirecto,  la  sutura  romboidal  y  la  de- 
bilitacion del  rmisculo  antagonista,  son  los  tres  factores  importan- 
tisimos  que  nos  autorizan  a  considerar  como  nuevo  el  procedimiento 
quirurgico  que  practicamos  nosotros,  para  corregir  el  estrabismo. 


A  NEW  PROCEDURE  IN  THE  EXCISION  METHOD 
OF  PTERYGIUM  OPERATION 

DR.  E.  CAMPODONICO 
Lima,  Peru 

It  is  a  well-known  fact  that  pterygium  is  of  frequent  occurrence  in 
the  tropics  as  compared  with  its  relative  rarity  in  the  temperate 
regions.  In  the  coastal  zone  of  Peru  it  is  especially  prevalent,  owing 
to  the  dusty  condition  of  the  air  consequent  on  the  dryness  of  the  soil 
and  the  lack  of  rainfall. 

In  my  one-year-long  visit  to  the  clinics  of  the  United  States  I  have 
seen  very  few  operations  for  pterygium,  whereas  here  in  Peru  it  is  an 
operation  of  almost  daily  occurrence.  My  experience  in  the  Euro- 
pean clinics  points  to  the  same  infrequency. 

With  such  an  ample  field  and  variety  of  cases  as  are  forthcoming  in 
the  Peruvian  ophthalmic  clinics  I  had  the  opportunity  of  lavishly 
trying  all  the  known  methods,  gauging  their  advantages  and  disad- 
vantages as  well.  Indeed,  our  outdoor  patients'  consulting  depart- 
ment of  the  Italian  hospital  in  Lima  has  an  average  daily  number  of 
150  ophthalmic  cases.  In  the  following  exposition  I  beg  to  outline 
a  procedure  which  has  given  me  the  best  results  for  a  period  of  over 
twenty  years. 

The  needed  instruments  are:  lid-speculum,  small  fixation  forceps, 
—preferably  one-toothed, — angular  keratome,  straight  or  curved  fine 
scissors,  fine  silk  suture,  and  occasionally  a  needle-holder. 

The  operation  is  performed  in  three  steps:  (1)  Dissection  of  the 
pterygium 's  head  out  of  the  cornea  and  adjacent  sclera  by  means  of 
the  angular  keratome;  (2)  excision  of  the  pterygium's  head  and  body 
by  means  of  small  scissors;  (3)  suturing  of  the  flaps. 

I  have  nothing  to  say  about  the  first  and  second  steps,  as  the  per- 
ormance  thereof  is  a  matter  of  routine  practice.  The  only  thing  I 
should  insist  upon  is  the  use  of  the  anesthetic  by  instillation,  not  by 
subconj unctival  injection,  as  the  areolar  infiltration  resulting  from  the 
injection  is  detrimental  to  the  accurate  subsequent  coaptation  of  the 
flaps. 

201 


202 


E.  CAMPODONICO 


The  third  step,  i.  e.,  suturing,  is  the  one  wherewith  I  shall  deal  with 
some  detail  on  account  of  the  decisive  influence  on  the  outcome  and 
ultimate  issue  of  the  whole  operation. 

The  placing  of  the  conjunctival  suture  and  cicatrix  in  a  position 
favorable  for  recurrence  is  the  paramount  disadvantage  of  most  of 
the  methods  in  vogue  for  the  extirpation  of  pterygium.  The  safest 
plan  is  to  remove  such  conjunctival  union  from  exposure  in  the 


Fig.  1. — Conjunctival  defect  after  excision. 

palpebral  fissure,  as  by  so  doing,  in  the  excision  operation,  we  actually 
lessen  the  proclivity  to  recurrence. 

Fig.  1  shows  the  conjunctival  defect  after  excision  of  the  pterygium. 

Our  method  consists  in  suturing  the  conjunctiva  to  the  point  a 
with  the  episcleral  tissue  and  conjunctiva  of  the  point  b,  as  is  shown 
in  Fig.  2.  Next  the  points  c  and  d  of  conjunctiva  are  united  by 
another  suture,  as  shown  in  Fig.  3. 

As  is  easy  to  understand,  the  essential  feature  of  this  method  is 
the  insertion  of  a  suture  which  is  passed  through  the  conjunctiva  of 
one  flap  at  a  point  a  (Fig.  1),  and  through  the  episcleral  tissue  and  con- 


New  Procedure  in  the  Excision  Method  of  Pterygium  Operation     203 


Fig.  2. — Conjunctiva  sutured  in  place. 


Fig.  3. — Second  conjunctival  suture. 


204  .  E.  CAMPODONICO 

junctiva  of  the  point  b.  The  points  a  and  b  (Fig.  1)  are  equidistant 
from  y.  Thus,  when  a  comes  to  b,  the  tract  a  y  overlaps  the  portion 
of  limbus  b  y.  The  point  a  is  perfectly  movable,  because  it  takes  the 
conjunctiva  only,  whereas  the  point  b  is  quite  steady  and  immovable 
by  reason  of  comprising  the  limbus  conjunctivas  and  episclera  as  well. 

Occasionally,  and  especially  in  cases  when  the  pterygium's  head  is 
large,  it  is  advisable  to  undermine  a  little  the  flap  a  in  order  to  avoid 
the  stretch  on  this  flap  when  a  is  anchored  to  6. 

On  drawing  the  flap  a  to  b  an  actual  overlapping  of  a  portion  of  the 
cornea  may  result;  this,  however,  is  quite  uneventful,  and  on  taking 
off  the  bandage  in  a  couple  of  days'  time  everything  will  be  found  in  a 
perfect  coaptation. 

Instead  of  making  the  lower  flap  movable  and  the  upper  one  fixed, 
we  may  just  as  well  do  the  reverse  and  anchor  a  loose  point  of  the 
upper  flap  to  the  episcleral  tissue  and  limbus  conjunctivas  of  the  lower. 
This  we  have  done  several  times,  namely,  in  cases  in  which  it  is  easier 
to  loosen  and  slide  the  upper  flap  than  the  lower.  We  prefer,  how- 
ever, the  first  way,  because  the  conjunctival  seam  is  thus  more  effi- 
ciently protected  by  the  agency  of  the  upper  lid  from  exposure.  At 
the  end  of  the  operation  it  will  be  found  also  that  fibers  which  had 
before  a  horizontal  direction,  now  have  a  vertical  one;  their  natural 
trend  of  growing  is  consequently  thwarted. 

A  still  further  advantage  in  removing  the  conjunctival  apposition 
line  from  the  horizontal  meridian  is  the  fact  that  by  so  doing  we 
eliminate  in  the  horizontal  line  the  presence  of  sutures  which  un- 
doubtedly act  as  a  stimulus  for  reproduction  of  connective  and  fibrous 
cicatricial  tissue,  just  exactly  in  a  place  where  it  is  least  desirable. 

The  eye  is  bandaged  for  seven  or  eight  days,  after  which  the  sutures 
are  removed.  The  bandage  is  changed  every  other  day.  Whenever 
possible,  it  is  a  good  plan  to  keep  both  eyes  bandaged  at  least  for  a 
couple  of  days. 

As  previously  stated,  in  a  place  like  Lima,  where  pterygia  are  espe- 
cially plentiful,  I  have  operated  many  hundreds  of  cases  by  the 
procedure  just  described  and  have  eagerly  and  abundantly  tried  every 
new  method  that  reached  my  acquaintance,  with  the  result  that  I 
always  gave  it  up  to  return  to  the  simple  course  I  have  outlined  above. 

SUMMARY 

The  most  salient  disadvantage  in  the  ordinary  excision  method  of 
pterygium  operation  is  the  placing  of  the  conjunctival  suture  and 


The  Subconjunctival  Excision  of  Pterygium  205 

cicatrix  in  the  horizontal  meridian,  i.  e.,  in  a  position  especially  favor- 
able for  recurrence. 

The  author's  procedure  consists  in  removing  the  suture  and  cicatrix 
as  much  as  possible  from  the  palpebral  fissure  by  simply  anchoring  a 
movable  and  nearly  middle  point  of  the  lower  conjunctival  flap  to  a 
fixed  and  steady  point  of  the  upper  flap,  namely,  to  the  episcleral  tissue 
and  limbus  conjunctives  of  the  upper  flap.  Thus  the  limbus  corneae, 
from  which  the  pterygium's  fibers  have  been  extirpated,  is  covered 
by  a  sound  stretch  of  conjunctiva  and  the  horizontal  trend  of  the 
fibers  is  thwarted  vertically. 


THE  SUBCONJUNCTIVAL  EXCISION  OF  PTERYGIUM 

DR.  S.  LEWIS  ZIEGLER 

Philadelphia 

That  pterygium  is  a  vascularized,  fleshy  growth  of  conjunctiva 
invading  the  cornea,  and  composed  chiefly  of  hypertrophied  subcon- 
junctival  tissue,  is  a  pathologic  fact  which  is  highly  significant  in  its 
relation  to  both  treatment  and  prognosis.  The  ancients  regarded 
pterygium  as  malignant  in  origin,  and,  like  other  neoplasms,  they 
removed  it  by  total  ablation.  Scarpa1  was  the  first  to  deny  this 
origin,  but  classified  it  as  a  varicosity  resulting  from  chronic  con- 
junctivitis. 

Alt2  hypothetically  ascribed  the  origin  of  pterygium  to  a  marginal 
corneal  ulcer,  although  he  could  not  demonstrate  this  in  his  prepara- 
tions. Goldzieher3  found  considerable  disturbance  of  the  corneal 
epithelium  around  the  head,  while  beneath  it  Bowman's  membrane 
was  detached  and  the  fibers  of  the  corneal  stroma  were  thickened. 
At  the  margins  he  described  small  cavities  dotted  with  epithelium 
and  other  signs  of  mucous  degeneration.  He  also  noted  episcleral 
thickening,  and  believed  that  corneal  ulceration  was  the  origin. 

Horner1  first  promulgated  the  view  that  pinguecula  and  pterygium 
were  two  stages  of  a  similar  pathologic  process.  Poncet,5  in  a  recent 
specimen,  found  no  evidence  of-  corneal  ulceration,  although  Bow- 
man's membrane  was  slightly  eroded  and  the  vessels  somewhat  dis- 
torted; but  there  was  no  sign  of  inflammatory  proliferation.  Al- 
though neoformation  of  tissue  was  absent,  he  did  observe  that  the 
elements  of  a  cicatrix  were  present.  In  a  few  preparations  he  found 


206  S.  LEWIS  ZIEGLER 

vibrios  and  spores  which  he  thought  might  be  responsible  for  the 
focal  point  of  the  affection  in  these  individual  cases. 

Fuchs,6  in  an  extensive  study  of  several  hundred  specimens,  both 
in  vivo  and  postmortem,  eliminated  ulceration  and  supported  the 
view  that  pinguecula  was  the  origin.  He  had  never  found  the  vibrios 
noted  by  Poncet,  nor  were  other  microorganisms  observed.  He 
occasionally  found  yellowish  spots  with  hyaline  aggregation,  and  in 
six  cases  he  noted  small  cystic  cavities  filled  with  a  clear  liquid.  De 
Schweinitz,7  Strachow,8  and  others  have  confirmed  this  observation 
by  reporting  similar  cases  of  cystic  formation  within  the  body  of  the 
pterygium. 

Panas,9  in  reviewing  the  pathology  of  pterygium,  called  attention 
to  its  macroscopic  resemblance  to  cicatricial  tissue.  He  further  de- 
clared that  the  theory  of  corneal  ulceration  is  founded  neither  on 
clinical  observation  nor  on  histologic  examination.  He  concluded 
that  the  primary  lesion  was  an  involutive  dystrophy  of  the  cornea 
with  secondary  hyperemia,  hypertrophy,  and  retraction  of  the  con- 
junctiva; that  there  was  a  predisposing  cause  in  the  individual,  to 
which  were  added  exciting  causes  due  to  prolonged  exposure  to 
irritants,  such  as  dust,  sand,  heat,  wind,  or  lacrimal  disturbances. 

Pterygium  should  always  be  removed — (a)  When  it  is  progressive; 
(6)  when  it  interferes  with  vision;  (c)  when  it  limits  ocular  motility; 
(d)  when  a  capital  operation  on  the  globe  is  planned;  or  (e)  when  it  is 
cosmetically  disfiguring. 

The  requisites  necessary  to  success  in  the  operative  treatment  of 
pterygium  are:  (1)  Thorough  removal  of  the  head,  leaving  clear 
corneal  tissue;  (2)  careful  excision  of  the  subconjunctival  tissue, 
especially  about  the  limbus;  (3)  complete  closure  of  the  conjunctival 
wound,  with  close  approximation  to  the  limbus;  (4)  the  avoidance  of 
conjunctival  tearing  and  tension;  (5)  rapid  primary  union,  with  as 
thin  a  conjunctival  flap  as  it  is  possible  to  secure. 

The  earliest  methods  resorted  to  for  the  removal  of  pterygium  de- 
pended upon  excision,  more  or  less  complete.  The  resulting  wound 
was  universally  left  open,  to  be  healed  by  granulation.  This  neglect 
was  responsible  for  many  cases  of  recurrence.  The  necessity  for  a 
complete  covering  of  the  scleral  defect  cannot  be  too  strongly  empha- 
sized as  a  precautionary  measure  to  obviate  such  a  danger.  It  is 
better  to  insert  a  suture  close  up  to  the  limbus,  and  if  necessary,  to 
include  the  scleral  and  episcleral  tissue,  in  order  to  fix  it  there  evenly 
and  thus  promote  firm,  smooth  healing.  Neglect  of  this  simple 


The  Subconjunctival  Excision  of  Pterygium  207 

technic  will  often  permit  the  formation  of  cicatricial  tissue,  which 
will  not  only  interfere  with  the  motility  of  the  subjacent  rectus 
muscle,  but  may  encourage  recurrent  or  pterygoid  growth. 

Another  defect  in  many  of  the  older  operations  arose  from  the 
neglect  to  remove  the  head  of  the  growth,  which,  if  progressive,  con- 
tinued to  encroach  upon  the  cornea.  Many  methods  have  been 
devised  for  the  successful  accomplishment  of  this  simple  essential, 
and  a  variety  of  instruments  have  been  suggested.  A  narrow  von 
Graefe  cataract  knife  is  the  knife  of  choice  adopted  by  the  majority 
of  operators.  As  a  rule,  this  is  entered  flatwise  beneath  the  con- 
stricted neck,  with  the  edge  turned  forward  and  the  head  cleanly 
shaved  off  from  the  cornea.  Others  select  Beer's  knife  for  the  same 
purpose,  because  its  angular  point  makes  it  easier  to  insert,  and  be- 
cause the  wider  blade  yields  a  clean,  broad  incision  that  is  safer  to 
make  and  freer  from  post-operative  tags  of  tissue.  Personally,  I 
prefer  to  use  Beer's  knife  as  a  dull  dissector,  first  making  firm  traction 
on  the  neck  with  forceps  and  then  applying  the  back  of  the  blade 
near  its  point  to  the  stretched-out  marginal  fibers.  These  will 
gradually  yield,  just  as  a  lichen  is  pulled  off  from  a  tree,  and  a  clean 
corneal  surface  is  secured.  If,  by  chance,  a  small  shred  of  tissue  is 
left  behind,  the  knife  should  be  reversed  and  the  blade  applied  as  a 
razor  to  cleanly  shave  the  corneal  surface.  The  ordinary  broad- 
pointed  scalpel  is  often  used  in  a  similar  manner.  Some  choose  the 
blunt-pointed  knife  of  Desmarres.  Others  prefer  to  use  the  angular 
keratome  or  Taylor's  broad  needle  to  accomplish  a  like  purpose,  the 
value  of  the  latter  having  been  strongly  urged  by  Black.10  A  bent, 
double-edged,  short  von  Graefe  knife  has  been  adopted  by  McRey- 
nolds,11  but  this  again  is  practically  identical  with  the  angular  broad 
needle  of  Taylor.  McReynolds  insists  that  shaving  the  cornea  is 
far  more  effective  in  his  climate  than  divulsion. 

Removal  of  the  head  by  blunt  dissection  has  been  warmly  advocated 
by  many.  Prince12  has  particularly  recommended  divulsion  with  a 
strabismus  hook  applied  successively  to  small  sections  on  each  side 
of  the  growth,  which  is  torn  loose  by  short,  jerky  movements  from  the 
neck  toward  the  apex,  until  all  the  filaments  are  severed  and  the 
cornea  stripped  clear.  The  strabismus  hook  "divulsor"  has  also 
been  made  up  with  a  beveled  edge  or  with  a  knife  edge,  and  also 
with  a  sharp  point.  Special  hooked  scissors,  such  as  Chadwick's, 
have  been  devised  for  this  purpose,  but  many  simply  use  the  closed 
blades  of  the  tenotomy  scissors  as  a  blunt  dissector.  .The  multi- 


20S  S.  LEWIS  ZIEGLER 

plicity  of  instruments  shows  that  there  is  no  really  important  advan- 
tage to  be  gained  from  the  use  of  one  over  the  other;  all  of  which 
emphasizes  the  fact  that  the  choice  of  an  instrument  is  a  mere  matter 
of  detail  in  the  technic  of  each  individual  operator. 

Curetment  of  the  corneal  surface  should  be  gently  made  if  any 
apical  fibers  remain  adherent.  The  Gallardo  corneal  curet,  the  small 
toothed  curets  of  Skeel  or  Ziegler,  and  the  hoe-shaped  corneal  spud 
have  all  been  employed  for  this  purpose.  Both  the  knives  of  Beer 
and  of  von  Graefe  have  been  used  to  shave  the  surface  of  the  cornea. 

The  galvanocautery,  as  suggested  by  Panas,  may  be  lightly  applied 
to  the  rough  corneal  surface  if  other  measures  should  fail  to  clear  it. 
This  is  of  particular  advantage  where  the  growth  is  so  adherent  as  to 
require  morcellation.  The  eschar  must  be  promptly  removed  with 
the  curet  and  ^  per  cent,  formalin  carefully  applied  to  prevent 
leukomatous  scarring. 

Accepting  the  theory  that  subconjunctival  hypertrophy  is  more  or 
less  cicatricial  in  character  and  possesses,  therefore,  a  persistent 
tendency  to  undergo  contraction,  and  that  it  is  this,  tissue  which 
invades  the  cornea  and  causes  recurrence,  I  conceived  the  idea  that 
the  thorough  removal  of  this  subconjunctival  tissue  would  not  only 
encourage  smooth  healing,  but  would  also  eliminate  the  danger  of 
recurrence.  It  is  likewise  my  belief  that  the  same  principle  holds 
good  in  the  surgery  of  symblepharon  or  other  growth  of  a  cicatricial 
character.  Acting  on  this  theory,  I  began,  in  1890,  to  practise  the 
following  simplified  method  of  subconjunctival  excision,  which  in 
my  hands  has  proved  to  be  not  only  a  cosmetic  success,  but  has  been 
absolutely  free  from  recurrence. 

Cocain  is  sufficient  as  an  anesthetic,  and  adrenalin  may  be  instilled 
as  a  hemostatic.  If  desired,  a  stronger  solution  of  cocain  (20  per 
cent.)  can  be  applied  directly  to  the  growth  with  an  applicator  while 
the  lids  are  held  open  to  avoid  contact  with  the  cornea.  Some  pre- 
fer to  inject  novocain,  1  per  cent.,  beneath  the  field  of  operation,  but 
the  consequent  edema  may  distort  the  outlines  of  the  growth. 

AUTHOR'S  METHOD  OF  SUBCONJUNCTIVAL  EXCISION 
First  Stage. — The  neck  of  the  pterygium  is  grasped  firmly  with 
rat-tooth  fixation  forceps,  drawn  tense,  and  the  marginal  fibers  of 
the  head  freely  divided  with  the  back  and  point  of  a  Beer's  knife, 
used  as  a  dull  dissector.  If  the  apex  is  unusually  adherent,  the  knife 
may  be  passed  beneath  the  neck  and  the  head  shaved  off  (Fig.  1). 


The  Subconjunctival  Excision  of  Pterygium 


209 


Second  Stage. — Still  grasping  the  apex  and  holding  it  tense,  both 
sides  of  the  pterygium  are  cut  loose  with  the  conjunctival  scissors, 
the  body  undermined,  and  the  flap  lifted  up  (Fig.  2). 

Third  Stage. — The  forceps  which  grasp  the  apex  are  now  handed  to 


Fig.  1. — First  Stage:  Head  removed  with  Beer's  knife  as  dull  dissector. 


Fig.  2. — Second  Stage:  Detaching  body  from  sclera  with  scissors. 


an  assistant,  who  continues  to  hold  the  flap  taut,  while  the  subcon- 
junctival  tissue  beneath  the  flap  is  grasped  by  a  second  pair  of  forceps 
and  carefully  dissected  off  from  the  conjunctiva  by  delicate  snips  of 
the  sharp-pointed  conjunctival  scissors  (Fig.  3).  When  the  con- 
junctival flap  is  freed  from  the  underlying  tissue  its  apex  is  excised  and 
14 


210 


S.  LEWIS  ZlEGLER 


the  remaining  flap  of  pure  conjunctiva  dropped  back  toward  the 
canthus. 

Fourth  Stage. — According  to  the  size  of  the  scleral  defect  to  be 
covered  I  resort  to  one  of  three  different  procedures — (a),  (6),  or  (c): 


Fig.  3. — Third   Stage:     Hypertrophied   subconjunctival    tissue    being   carefully 
dissected  from  conjunctiva  with  scissors. 


Fig.  4. — Fourth  Stage:    Sutures  inserted.     Juxtacorneal  one  anchored  in  sclera. 
Roll  of  conjunctiva  snipped  to  relieve  tension  and  smooth  it  out. 


(a)  //  the  pterygium  is  small,  the  conjunct! val  wound  is  closed  by 
two  sutures,  the  Juxtacorneal  one  being  anchored  in  the  sclera.  This 
may  cause  overlapping  of  the  corneal  margin,  which  is  corrected  by 
clipping  the  cuff -like  roll  of  conjunctiva  in  several  places  with  scissors 


The  Subconjunctival  Excision  of  Pterygium  211 

and  pushing  it  back.  As  the  conjunctiva  again  smooths  out  these 
"pie-cuts"  open  into  small,  diamond-shaped  perforations  which  relieve 
all  tension  and  heal  smoothly  (Fig.  4). 

(6)  //  the  wound  is  larger  and  the  conjunctival  tension  is  great,  two 
short  paracorneal  incisions  (5  mm.)  are  made,  above  and  below,  the 
conjunctival  edges  undermined,  and  the  wound  united  by  two  sutures, 
the  juxtacorneal  one  being  anchored  in  the  sclera. 

(c)  //  the  denuded  area  is  extremely  large,  two  sets  of  liberating 
incisions  are  made,  the  paracorneal  incisions  above  and  below  being 
supplemented  by  incisions  made  parallel  to  the  first  (5  to  10  mm.), 
and  placed  at  the  canthal  extremity  of  the  wound.  The  quadrilateral 
flaps  thus  formed  are  closed  with  three  sutures,  the  juxtacorneal 
one  being  anchored  in  the  sclera,  and  a  mattress  anchor  suture  placed 
at  the  canthal  intersection,  as  in  Knapp's  double  transplantation. 

AFTER-TREATMENT. — As  a  rule,  the  simple  technic  of  the  first  pro- 
cedure (a)  is  wholly  adequate  to  close  the  wound .  Healing  is  smooth 
and  prompt,  owing  to  the  avoidance  of  extensive  dissection  and  the 
freedom  from  tension.  A  monocular  dressing  is  applied  for  three  or 
four  days.  The  Liebreich  patch  may  be  worn  a  day  or  two  longer. 
The  stitches  can  be  removed  on  the  third  or  fourth  day.  Boric  acid 
irrigation  is  used  once  daily  until  the  pad  is  discarded,  then  three 
times  a  day.  The  eye  usually  remains  red  for  one  or  two  weeks. 
If  there  is  lacrimal  disturbance,  the  tear-duct  should  be  dilated  at 
least  ten  days  before  the  pterygium  operation  is  attempted. 

The  principle  of  Subconjunctival  excision  of  the  hypertrophied 
adventitious  tissue  can  be  applied  as  well  to  any  other  of  the  well- 
known  pterygium  procedures.  I  have  tried  it  in  McReynolds'  modi- 
fication of  the  technic  of  Desmarres,  Sr.,  and  found  it  successful  in 
producing  a  much  thinner  flap,  which  made  the  procedure  a  greater 
success. 

To  recapitulate  briefly  the  advantages  of  Subconjunctival  excision 
of  pterygium,  I  should  say  that  the  four  factors  most  worthy  of  con- 
sideration are — (1)  Reduction  of  a  thickened  flap;  (2)  avoidance  of 
extensive  dissection;  (3)  freedom  from  conjunctival  tension,  and  (4) 
prevention  of  recurrence. 

REFERENCES 

1.  Scarpa:  TraitS  des  Malad.  des  Yeux,  1821,  i,  261. 

2.  Alt:  Anat.  des  Auges,  1880,  52. 

3.  Goldzieher:   Centralb.  f.  prakt.  Augenh.,  1878. 

4.  Homer:  Corresp.  f.  Schweiz.  Aerzte,  1875,  554. 


212  E.  CAMPODONICO  AND  S.  LEWIS  ZIEGLER 

5.  Poncet:  Arch.  d'Ophtal.,  1881,  i,  31. 

6.  Fuchs:  Graefe's  Arch.  f.  Ophth.,  1891,  iii,  143;   1892,  ii,  1. 

7.  de  Schweinitz:  Trans.  Coll.  Phys.  Phila.,  1908,  319. 

8.  Strachow:  Klin.  Monatsbl.  f.  Augenheilk.,  1908,  563. 

9.  Panas:  Traite  des  Malad.  des  Yeux,  1894,  T.  ii,  262. 

10.  Black:  Ophthal.  Rec.,  December,  1897,  650. 

11.  McReynolds:    Jour.  Am.  Med.  Assn.,  1932,  296.    Ophthal.  Rec.,  November, 

1909,  526.     Ophthalmoscope,  March,  1914. 

12.  Prince:  Arch.  Ophthal.,  January,  1885,  16. 

DISCUSSION  OF  PAPERS  OF  DRS.  CAMPODONICO  AND  ZIEGLER 
DR.  JOHN  0.  MCREYNOLDS  (Dallas,  Texas) :  In  discussing  the  papers  of 
Drs.  Ziegler  and  Campodonico  three  distinct  observations  are  relevant: 

1.  For  small  and  medium  size  pterygia  in  localities  that  do  not  strongly 
predispose  to  the  development  or  recurrence  of  the  growth  many  different 
surgical  measures  may  yield  excellent  results.     The  crucial  test  is  made, 
however,  in  the  large  vascular  types  associated  with  atmospheric  conditions 
favorable  for  the  production  of  this  condition. 

2.  The  second  observation  relates  to  the  removal  of  the  head  of  the  ptery- 
gium  from  the  cornea.     In  my  experience  the  essential  thing  is  an  absolutely 
complete  and  smooth  removal  of  every  vestige  of  the  head,  leaving  only  smooth 
clear  corneal  tissue  beneath.     This  eliminates  all  forms  of  divulsion,  curetting 
and   cauterization,   and   requires   a   dependable   cutting  instrument.     For 
ordinary  cases  a  Graefe  knife  is  sufficient,  but  for  exceedingly  large  pterygia, 
covering  practically  y9^  of  the  cornea,  the  most  effective  instrument  is  a  very 
sharp  angular  keratome  not  broader  than  2  mm.  at  its  base.     This  permits 
the  surgeon  to  apply  the  cutting  edge  in  such  a  way  to-  the  spherical  surface 
of  the  cornea  that  it  can  shave  off  every  particle  of  the  growth  without  going 
too  deep  into  the  corneal  stroma. 

3.  The  third  observation  relates  to  the  removal  and  disposition  of  the  body 
of  the  growth  with  the  necessary  covering  of  the  denuded  area  of  the  sclera. 

Each  of  the  papers  emphasizes  a  feature  of  value.  The  paper  of  Dr. 
Ziegler  dwells  upon  the  importance  of  removing  the  redundant  subcon- 
junctival  tissue.  The  paper  of  Dr.  Campodonico  dwells  upon  the  importance 
of  eliminating  all  sutures  in  the  palpebral  opening.  Both  of  these  objects 
are  worthy  of  every  consideration  and  both  can  be  accomplished  by  means 
of  a  single  suture  which  fixes  the  growth  in  the  lower  cul-de-sac,  utilizing  the 
attenuated  conjunctival  element  of  the  pterygium  in  covering  the  scleral 
defect,  taking  care  that  there  shall  be  no  break  along  the  superior  border  of 
the  growth  which  would  allow  the  wound  to  gape  and  necessitate  the  intro- 
duction of  sutures  in  the  palpebral  opening. 

DR.  A.  E.  PRINCE  (Springfield,  111.):  The  subconjunctival  removal  of 
pterygium  is  a  practice  which  I  have  followed  for  many  years  in  cases  where 
there  is  a  large  amount  of  hypertrophied  tissue,  and  this  I  have  done  by  simply 
excising  the  fleshy  portion  after  laying  back  the  superficial  conjunctiva. 

I  wish  particularly  to  speak  of  a  method  of  treating  pterygium  in  another 
class  of  cases;  those  which  are  attenuated,  spread  over  considerable  area,  or 


The  Excision  of  Pterygium  213 

are  very  minute,  and  have  no  flesh  under  them.  They  hardly  justify  a  sur- 
gical operation  if  it  can  be  avoided.  In  those  cases  I  have  found  that  by  taking 
some  carbon  dioxid  ice,  having  previously  cocainized  the  cornea,  and  applying 
the  ice  at  intervals  of  about  a  week,  the  pterygium  will  disappear.  I  think 
what  takes  place  is  a  destruction  of  the  blood  globules  in  the  minute  capillaries 
and  subsequent  atrophy  of  the  tissue.  In  an  old  lady,  where  three-fourths 
of  the  cornea  was  covered  and  vision  reduced  to  1  /200,  four  treatments 
brought  vision  to  20  /200.  The  application  should  be  one  second. 

Carbon  dioxid  is  simple  to  handle.  You  can  get  a  tank  of  the  gas  in  almost 
every  city  where  there  is  a  soda  fountain.  Suspend  it  on  the  wall  with  the 
portion  at  which  the  faucets  are  attached  at  an  angle  of  about  twenty  degrees, 
so  that  all  of  the  impurities  will  be  at  the  top  and  the  liquid  come  to  the  bot- 
tom. Have  a  plumber  make  a  little  reducer,  the  fine  end  of  which  will  fit 
an  ear  speculum.  The  ear  speculum  is  then  put  into  this  reducer,  and  a  nap- 
kin, folded  about  eight  thicknesses,  is  held  securely  over  the  ear  speculum. 
Upon  opening  the  faucet  at  the  end  of  the  tank  the  liquid  carbon  dioxid  fills 
the  ear  speculum  and  the  portion  which  escapes  in  gaseous  form  through  the 
folded  napkin  freezes  that  which  remains  in  the  ear  speculum  and  is  a  solid 
cast  of  carbon  dioxid  ice.  This  can  be  made  to  take  any  shape  desired  by 
cutting  it  with  a  knife  or  scissors.  This  use  of  carbon  dioxid  ice  for  pterygia 
was  described  in  Archives  of  Ophthalmology  in  the  year  1916,  under  the  cap- 
tion, "Carbon  Dioxide  Ice  in  the  Treatment  of  Trachoma,  Vernal  Catarrh, 
and  Pterygiums."  I  wish  to  add  a  previous  report  of  a  case  which  proved 
intractable  after  six  attempts  at  excision,  and  was  entirely  cured  by  eight 
weekly  applications  of  the  carbon  dioxid  ice. 

DR.  S.  LEWIS  ZIEGLER  (closing) :  I  have  not  had  an  opportunity  of  trying 
the  carbon  dioxid  snow,  recommended  by  Dr.  Prince,  but  it  is  a  good  sug- 
gestion for  the  attenuated  cases ;  in  the  fleshy  cases  I  have  sometimes  resorted 
to  galvano-cautery  puncture  similar  to  the  operation  I  once  suggested  for 
ectropion,  except,  of  course,  that  you  pass  your  needle,  which  must  be  a  fine 
one,  parallel  with  the  surface  of  the  globe  instead  of  passing  the  tip  into  the 
tissue  vertically,  because  you  must  not  cauterize  the  sclera,  since  Knapp  has 
shown  there  is  danger  of  disturbance  of  the  aqueous  and  ultimate  cataract. 
You  can  also  resort  to  electrolysis.  Another  method  is  high  frequency 
desiccation,  as  practised  by  Dr.  Clark,  of  Philadelphia.  In  some  cases  of 
keloid  that  has  been  of  value. 

The  manner  of  removing  the  head  of  the  pterygium  is  an  individual  ques- 
tion. I  happen  to  prefer  Beer's  knife;  Dr.  McReynolds  uses  the  broad 
needle,  and  Dr.  Prince  practises  divulsion — one  selects  that  which  is  most 
effective  in  his  own  hands.  Where  there  is  morcellation  following  removal 
of  the  growth  it  may  be  necessary  to  cauterize  the  small  particles  left.  If  you 
do  and  wish  to  avoid  leucoma  of  the  cornea,  it  would  be  wise  to  remove  the 
eschar  by  curetting  and  applying  weak  formalin,  one-half  of  one  per  cent. 

Slicing  off  the  cornea  has  been  advocated  by  some  and  criticized  by  others. 
Dr.  McReynolds  thinks  in  his  climate  it  is  most  successful.  In  the  literature 
are  cases  in  which  severe  ulceration  has  followed,  so  that  again  is  a  matter  of 
individual  choice.  The  French  school  generally  favors  the  galvano-cautery. 


214  FRANCISCO  POYALES 

They  cauterize  only  the  area  of  the  cornea  where  the  head  has  been  removed. 
In  regard  to  cases  where  there  is  considerable  ulceration  of  the  cornea  after 
operation,  I  think  the  suggestion  of  Dr.  Pontius,  of  Philadelphia,1  in  regard 
to  the  use  of  full  strength  adrenalin  for  regeneration  of  the  cornea,  is  an  ex- 
cellent one.  It  has  proved  most  successful  in  my  hands. 


LA  TUBERCULOSIS  OCULAR  INFANTIL 

DR.  FRANCISCO  POYALES 
Madrid,  Espana 

En  la  patologia  ocular  del  nino,  el  capitulo  de  la  tuberculosis 
aparece  estudiado  de  un  modo  incomplete,  sobre  todo  en  lo  que  se 
refiere  a  la  comprobacion  anatoma-patologica  de  las  lesiones. 

De  nuestro  material  clinico  hemos  utilizado  tres  casos,  en  los  que 
fue  necesario  practicar  la  enucleacion  por  lesiones  graves  y  como 
medio  profildctico  y  terapeutico. 

El  estudio  histologico  de  estos  globes  oculares  es  el  material  uti- 
lizado para  esta  conferencia,  pues  en  ellos  hemos  podido  determinar 
procesos  tuberculosos  como  etiologicos  de  los  graves  transtornos  que 
presentaban  a  nuestra  observacion  clinica. 

Los  procesos  tuberculosos  primaries  del  globo  ocular  ofrece  para 
el  diagnostico  clinico  gran  dificultad,  pueden  confundirse  con  lesiones 
inflamatorias  de  tipo  cronico,  y  no  presentan  estigmas  precisos  para 
su  diagnostico  diferencial,  esto  unido  a  que  pueden  no  existir  mani- 
festaciones  en  ninguna  otra  parte  del  organismo,  ausencia  de  ante- 
cedentes  familiares  reaction  de  Pirquet  negativa,  ningiin  antecedente 
morboso  ocular. 

Las  manifestaciones  secundarias  corresponden  con  frecuencia  a 
enfermos  de  tuberculosis  intestinal  y  pulmonar,  existe  antecedentes 
familiares,  reacci6n  de  pirquet  positiva,  terreno  abonado  a  la  infeccion, 
ataques  repetidos  de  conjuntivitis  pustulosa  o  flictenular,  en  esta 
forma  el  diagnostico  clfnico  es  mas  sencillo. 

No  haremos  ahora  la  description  de  sintomas  clinicos  tan  variados 
como  ofrece  la  tuberculosis  ocular.  En  el  ojo  humano  constituido 
por  tres  capas  de  naturaleza  tan  distinta  como — cornea,  esclerotica, 
iris,  ciliar  coroides,  retina  y  optico — es  posible  observar  formas  sim- 
ples de  infeccion  de  estas  membranas  o  combinaciones. 

Siempre  que  es  un  proceso  cronico  o  agudo,  no  obtengamos  mejoria 
por  los  medios  terapeuticos  corrientes  y  la  investigation  de  otro  tipo 
1  N.  Y.  Med.  Jour.,  1912,  p.  637. 


La  Tuberculosis  Ocular  Infantil  215 

de  infeccion  resulte  negativa  debemos  pensar  en  una  lesion  tuber- 
culosa. 

Cuando  el  globo  ocular  es  atacado  de  tuberculosis  se  destruye  antes 
de  generalizarse  la  infeccion,  en  un  raismo  globo  es  posible  encontrar 
desde  la  zona  inflamatoria  o  productiva,  hasta  la  zona  gaseosa; 
zonas  de  propagation,  lesiones  mas  avanzadas  o  intensas  en  relacion 
a  la  resistencia  de  la  membrana. 

No  podemos  excluir  la  posibilidad  de  la  generalization  si  tenemos 
en  cuenta  la  emigration  bacilar  por  vias  sangineas,  solo  favorece  a  la 
localization  ocular  la  capilaridad  de  los  vasos  en  los  plexos  arteriales 
y  venosos,  los  bacilos  que  resisten  al  ataque  de  los  leucocitos  poli- 
nucleares,  quedan  detenidos  en  los  vasos  por  un  trombus  fibrinosos. 

Nuestro  estudio  va  a  quedar  limitado  al  globo  ocular  propiamente 
dicho  prescindiendo  de  los  anejos,  y  se  las  manifestaciones  tuber culosa 
de  la  conjuntiva. 

El  problema  terapeutico  de  la  tuberculosis  ocular  queda  reducido 
a  las  manifestaciones  primarias,  debe  intentarse  un  tratamiento 
general  apropiado  a  estos  casos,  el  local  en  relacion  a  la  sintomatologia, 
si  nada  se  consigue,  asi  el  proceso  avanza  y  la  funcion  visual  estd, 
completamente  abolida,  se  impone  la  enucleacion  como  medio  pro- 
filactico. 

HISTORIAS  CLINICAS 

CASO  1. — Nino  de  nueve  anos. 

Diagnostico. — Esclero  queratitis  con  irido  ciclitis  cronica,  0.  I. 

Sin  antecedentes  familiares — Wassermann  negative) — Arneth  a  la  izquierda 
— Pirquet  negativo — Dolores  en  el  ojo — Hipotension  ocular — Vision  cero — 
No  presenta  sintomatologia  tuberculosa  en  ninguna  parte  del  organismo — 
Desnutricion.  No  mejora  con  un  tratamiento  apropiado. 

Etiologia  probable — Tuberculosis. 

Enucleacion  y  prescription  de  tonicos  generales.  Estudio  histologico  del 
globo  ocular.  Inclusion  en  celuidina — Coloraci6n  de  los  cortes  por  el  metodo 
Van  Gieson — Hematoxilina  y  eosina. 

Escler6tica  (Fig.  1). — Nodulos  situados  casi  en  el  limite  exteri<fr  de  la 
esclerotica,  perfectamente  limitados  y  rodeados  de  terreno  normal. 

Celulas  gigantes  caracteristicas  de  trecho  en  trecho  dispuestas  irregular- 
mente  de  gran  talla  redondeadas  dos  en  el  niicleo  superior  y  una  en  el  in- 
ferior. 

Espesamiento  total  de  la  escler6tica  producido  por  distension  de  los  espacios 
lacunares,  llenos  de  celulas  de  pepueno  tamano,  redondas  provistas  de  nu- 
cleo,  recordando  leucocitos  emigrados  de  territorios  vasculares  inmediatos. 

Esta  zona  de  infiltraci6n  d&  la  imagen  de  un  proceso  de  escleritis  sin 


216 


FRANCISCO  POYALES 


apellido,  es  la  verdadera  zona  productiva,  primera  fase  de  la  infecci6n  tu- 
berculosa. 

Focos  tuberculoses  mas  antiguos  en  fase  de  degeneration  caseosa.  Existen 
verdaderos  oquedades,  pe"rdidas  de  sustancia,  rellenas  de  una  masa  turbia 
semis61ida,  sembrada  de  gran  cantidad  de  granulaciones  de  naturaleza  grasa 
o  prote"ica. 

Es  el  resultado  de  un  proceso  de  desintegraci6n  celular  por  desecaci6n  del 
protoplasma  y  destruction  del  nucleo  este  proceso  degenerativo  dd  origen  a 
las  granulaciones  que  rellenan  las  cavernas. 

La  estructura  histologica  de  la  escler6tica  esencialmente  constituida  por 
haces  de  tejidos  conjuntivo  de  direcciones  cruzadas — antero-posteriores — 


Fig.  1. — N6dulos  tuberculoses  situados  en  el  limite  exterior  de  la  escler6tica. 

traversales — y  oblicuo  dan  a  esta  capa  pobre  en  elementos  basculares  grandes 
condiciones  de  resistencia  a  la  propagation. 

Sin  embargo  la  infection  tuberculosa  de  la  esclerotica  misma  se  propaga  en 
otras  direcciones  hacia  el  interior  buscando  la  coroides  al  exterior  por  el 
punto  de  menor  resistencia  (vasa  vorticosa)  a  la  cdpsula  de  Tenon  dando 
origen  a  las  tenonitis  tuberculosas  (Fig.  2).  Hacia  adelante  por  el  limbo 
esclero  corneal  a  la  c6rnea  y  por  su  proximidad  en  esta  regi6n  a  la  raiz  del  iris 
y  cuerpo  biliar. 

Pero  antes  de  pasar  a  describir  las  manifestations  tuberculosas  en  la 
c6rnea  iris  coroides  y  nervio  6ptico  haremos  el  estudio  detallado  de  un  poco 
tuberculoso. 


La  Tuberculosis  Ocular  Infantil  217 

Celulas  gigantes  (Fig.  3). — Se  destaca  en  el  centre  de  la  preparation  una 
celula  gigante,  punto  de  referencia  esencial  para  el  diagn6stico  de  la  infeccidn 
tuberculosa. 

Son  de  gran  talla  40  a  70  micras  de  forma  redonda  o  polio"  drica,  poseen 
numerosos  niicleos  algunas  veces  ma's  de  40  so  encuentran  situados  en  la 
periferia  formando  una  corona  alrededor  del  protoplasma. 

El  numero  de  celulas  gigantes  varia  mucho,  en  nuestra  reparaci6n  es 
posible  distinguir  tras  casi  juntas,  en  otras  zonas  aparece  una  aislada  en  otras 
no  hay  celulas  gigantes. 

En  la  constitution  del  m6dulo  tuberculososo  se  encuentran  innumerables 


Fig.  2.— Propagation  de  la  infecci6n  tuberculosa  de  escler6tica  a  cdpsula  de  Tenon. 

celulas  conectivas  fusiformes  de  nucleo  alargado  dispuestas  irregularmente  en 
capas  concentricas. 

Los  fasciculos  conectivos  son  tanto  ma's  escaso  cuanto  mds  nos  acercamos 
al  centro  del  foco. 

Al  lado  de  estos  elementos  celulares  se  encuentran  innumerables  celulas 
pequenas  de  nucleo  redondo,  que  recuerdan  en  un  todo  leucocitos  emigrados. 

Existen  celulas  cebadas  de  Ehrlich  que  tienen  como  caracter  ser  mono- 
nucleares  con  granulaciones  protoplasmaticas  que  se  tinen  en  rojo  por  la 
tionina. 

Como  fase  anterior  de  las  celulas  gigantes  es  posible  descubrir  elementos 
epitelioides,  con  pusculos  grandes  con  nucleo  grande  y  generalmente  en  vias 
de  segmentaci6n. 


218 


FRANCISCO  POYALES 


Fig.  3. — Foco  tuberculosa — celulas  gigantes. 


Fig.  4. — Esclero-queratitis  tuberculosa. 


La  Tuberculosis  Ocular  Infantil 


219 


La  propagation  de  la  infection  tuberculosa  de  la  escler6tica  a  c6rnea  en 
nuestro  caso  determina  una  localization  poco  frecuente  que  se  denoraina 
esclero-queratitis . 

En  la  literatura  oftalmologica  segun  la  referencia  hecha  por  Morax,  en  su 
libro  Pathologie  oculaire  1921  solo  existen  publicados  tres  casos  de  Wem- 
merslager  y  otro  de  Oreste. 

Esclero-queratitis  tuberculosa  (Fig.  4)  las  primeras  alteraciones  aparecen 
en  la  proximidad  de  la  insertion  de  los  musculos  rectos  y  aumentan  de  un 
modo  progresivo  hasta  ocupar  el  maximum  en  la  linea  escleroccorneal. 

Constituye  un  peligro  enorme  para  la  raiz  del  iris  y  el  cuerpo  ciliar  aunque 
la  resistencia  es  grande,  en  nuestro  caso  en  este  punto  el  iris  y  ciliar  estdn 


Fig.  5. — Tuberculosis  de  la  raiz  del  iris. 

indemnes,  sin  embargo  en  otra  zona  que  vereis  en  la  Fig.  5  podreis  apreciar 
al  proceso  de  propagaci6n  a  la  raiz  del  iris.  La  c6rnea  sufre  una  proliferaci6n 
bastante  marcada  de  su  epitelio  anterior  ofreciendo  un  aspecto  francamente 
ondulado. 

La  sustancia  propia  de  la  cornea  se  modifica  y  es  posible  apreciar  infiltra- 
tion leucocitaria  en  el  tercio  anterior  de  las  Idminas  de  la  c6rnea,  correspon- 
diendo  el  maximud  a  la  linea  esclero  corneal,  es  imposible  encontrar  celulas 
gigantes  se  confirma  el  diagnostico  por  las  lesiones  tuberculosas  de  las  otras 
zonas. 

En  las  Idminas  anteriores  de  la  cornea  existen  vasos  neoformados  colocados 
muy  pr6ximos  a  la  membrana  de  Bowman  sin  atravesarla.  Alrededor  de 


220  FRANCISCO  POYALES 

estos  vasos  la  infiltraci6n  leucocitaria  mononuclear  es  muy  marcada  existe 
tambie'n  en  la  pared  del  vaso  y  adheridos  a  la  tunica  interior. 

Al  nivel  de  la  esclerotica  las  lesiones  estdn  relativamente  ma's  marcada  s 
que  en  la  c6rnea,  el  espesor  del  segmento  anterior  de  la  escler6tica  es  por  lo 
menos  doble  del  espesor  normal.  Esto  es  debido  a  una  infiltraci6n  celular 
que  despega  las  Idminas  de  la  escler6tica  y  a  una  dilataci6n  de  los  vasos  en 
particular  la  capa  de  los  vasos  superficiales  de  la  esquer6tica,  a  trechos  la 
infiltraci6n  forma  verdaderos  nodulos,  estas  infiltraciones  disniinuyen  a 
medida  que  se  acerca  a  la  regi6n  ecuatorial.  En  nuestro  caso  presenta  el  iris 
focos  tfpicos  de  infeccion  tuberculosa  igual  que  uno  de  los  casos  descritos  por 
Wemmerslagen,  es  posible  encontrar  de  trecho  en  trecho  zonas  transparentes 
que  son  el  resultado  de  una  verdadera  condensaci6n  del  tejido  sin  sufrir 
necrosis  por  coagulaci6n. 

Es  muy  interesante  el  estudio  de  la  membrana  de  Descemet  aparece 
ondulada  y  despegada  en  algunos  puntos  de  las  l&minas  internas  de  la  cornea. 

La  capa  endotelial  presenta  en  algunos  puntos  doble  pila  de  ce*lulas, 
aparece  interrumpida  al  nivel  de  la  soldadura  irido-corneana,  por  estas 
rupturas  se  escapan  al  dngulo  de  la  cdmara  anterior  en  sudados  productos 
del  proceso  inflamatorio  de  cornea  e  iris. 

En  nuestra  preparaci6n  existe  disminuci6n  en  profundidad  de  la  cdmara 
anterior  por  expresamiento  del  iris.  En  41  existen  n6dulos  tuberculoses 
agrupados  con  tendencias  de  invasion  al  cuerpo  ciliar. 

Su  Iocalizaci6n  corresponde  a  la  cara  anterior  del  iris  y  muy  pr6ximo  al 
mismo  dngulo  irido-corneal. 

Miden  los  nodulos  dos  m.m.  en  extensi6n  en  el  examen  vivo  aparecen  de 
un  color  gris  amarillento,  el  colos  ma's  palido  de  la  zona  central  corresponde 
a  la  zona  de  necrosis. 

Las  alteraciones  histologicas  ma's  interesantes  son : 

La  destrucci6n  casi  total  de  la  capa  epiterial  anterior,  ausencia  completa 
de  las  criptas  de  Fuchs,  en  algunos  puntos  es  posible  recordarlas  por  la  ausencia 
de  la  membrana  basal,  dando  lugar  a  verdaderos  islotes  de  leucocitos  mono- 
nucleares. 

La  membrana  basal  anterior  aparece  ondulada,  pero  sin  romperse  vaso  de 
nueva  formaci6n  se  apoyan  en  ella  sin  perforarla. 

En  la  sustancia  propia  del  iris  constituida  principalmente  por  fibras 
musculares  lisas  y  estroma  conjuntivo  se  encuentran  innumerables  celulas 
conectivas  fusiformes  de  nucleo  alargado  y  dispuestas  en  capas  concentricas. 

Las  granulaciones  pigmentarias  libres  se  agrupan  irregularmente  alrededor 
del  foco  tuberculoso  y  dan  la  sensaci6n  de  desorden  y  enmascaran  los  detalles 
finos  de  estructura. 

La  membrana  basal  posterior  aparece  en  muchos  sitios  rota  y  sobre  ella  en 
grupos  irregulares  aparecen  acumulados  las  ce"lulas  epiteliales  pigmentadas 
de  la  capa  posterior  del  iris. 


La  Tuberculosis  Ocular  Infantil 


221 


En  las  arterias  se  encuentran  infiltraci6n  leucocitaria  en  las  paredes  y 
muchos  de  estos  elementos  adheridos  al  endotelio.  Las  arterias  ciliares 
largas  y  cortas  posteriores  igual  que  las  ciliares  anteriores  son  la  via  de 
propagacion  del  proceso  tuberculoso  a  cuerpo  ciliary  coroides,  aunque  nuestro 
caso  no  hemos  de  olvidar  la  propagaci6n  directa  desde  la  escler6tica.  Focos 
tuberculosos  en  coroides  (Fig.  6). 

Es  la  membrana  del  globo  ocular  que  con  mas  frecuencia  parece  la  loca- 
lizacion  tuberculosa  en  terreno  abonado  por  lo  intricado  de  su  red  vascular. 

Se  presenta  bajo  tres  aspectos  distintos:  Tuberculosis  difusa,  miliar  y 
tuberculoma. 

En  nuestro  caso  corresponde  al  tipo  de  la  tuberculosis  difusa,  es  posible 


Fig.  6. — Focos  tuberculosos  de  la  coroides. 

encontrar  celulas  epiteliales,  celulas  gigentes,  infiltracion  leucocitaria,  des- 
aparicion  del  espacio  supra-coroides  de  Schwalbe,  es  decir  de  los  espacios  libres 
constituidos  por  un  sistema  de  trab6culas  o  laminillas  conjuntivas  que  estdn 
llenos  de  leucocitos  mono-nucleares,  la  linea  de  demarcaci6n  de  escler6tica  a 
coroides  es  sinuosa. 

El  estroma  coroideo  cohstituido  por  fibras  de  tejido  conjuntivo,  elasticas 
finas,  musculares  lisas,  de  Muller  aparece  por  los  elementos  de  infiltracion 
dificultando  la  circulaci6n  de  arterias  y  venas  por  comprensi6n. 

Los  capilares  de  la  membrana  de  Bruch  estdn  obliterados. 

La  membrana  vitrea  esta  aumentada  de  espesor  tiene  un  aspecto  fibrilar 
en  conjunto,  ha  desaparecido  la  porci6n  lisa  que  mira  la  retina. 


222 


Tuberculoma  de  coroides. — La  tuberculosis  de  coroides  en  esta  forma,  s6lo 
se  puede  diagndsticar  como  tal  en  los  primeros  momentos  de  su  desarrollo  al 
aumentar  de  volumen  el  tuberculoma  produce  desprendimiento  de  retina  y 
glaucoma  secundario  que  hace  imposible  el  diagn6stico  con  el  oftalmocopio. 

La  conducta  mds  prudente  en  estos  casos  es  practicar  la  nucleacion  por  la 
posibilidad  de  la  existencia  de  un  sarcoma.  Una  vez  enucleado  el  ojo  el 
estudio  hist616gico  puede  aclarar  el  diagn6stico. 

Tuberculosis  miliar  de  nervio  optico. — Esta  preparacion  nos  indica  la 
posibilidad  de  infectarse  el  ojo  de  un  proceso  meningeo  tuberculos  o  que  la 
meninge  se  tubertfulice  por  generalizaci6n  de  un  proceso  ocular  (Fig.  7). 


Fig.  7. — Tuberculosis  miliar  de  nervio  6ptico. 


En  esta  preparacion  se  distingue  con  toda  claridad  focos  tuberculoses  con 
sus  celulas  gigantes.  Focos  necroticos  que  da  como  resultado  la  destruccion 
de  los  elementos  nerviosos  (cilindro  ejes). 

CASO  2. — Diagnostico:  Glaucoma  secundario — post  hemorragfa  vitrea  y 
en  cdmara  anterior. 

Nina  de  13  afios  sufrio  un  golpe  en  el  ojo  derecho  hace  tres  anos,  desde 
entonces  comienza  a  perder  vista  sin  ningun  dolor,  el  ojo  se  le  hizo  mds  peque- 
no,  hie"  diagn6sticado  de  irido-ciclitis  trail  mdticas.  Hace  mds  de  un  ano  ha 
perdido  totalmente  la  vision  de  su  ojo  derecho. 

Antecedentes :  El  padre  muri6  tuberculoso  tiene  Wassermann  negative — 
Pirquet  positive  no  existe  hemofilia — desnutrici6n — corficiente  de  Arneth  a 
la  izquierda.  Padeci6  de  pequeno  un  tumor  bianco  de  rodilla. 


La  Tuberculosis  Ocular  Infantil  223 

En  el  momento  de  esta  observaci6n  padece  intensos  dolores  glaucoma 
agudo  no  tiene  perfection  luminosa,  y  ante  el  temor  de  una  cosa  tumoral, 
cuerpo  extrano  intraucular  o  la  posibilidad  de  un  proceso  cr6nico  tuberculoso 
enucleamos  el  ojo  como  medio  profilactico. 

Examen  histologico  del  globo  ocular. — Inclusi6n  en  celuidina. — Cortes 
tenidos  por  ematoxilina  y  eosina. 

Las  lesiones  que  hemos  encontrado  en  este  globo  ocular  difieren  totalmente 
de  las  descritas  en  el  caso  anterior. 

Son  lesiones  que  denominaremos  terciarias  desde  luego  tuberculosas  al 
eliminar  la  existencia  de  tumor  y  cuerpo  extrano. 

Teniendo  presente  el  tipo  degenerativo  de  las  lesiones  la  reacci6n  de  Pir- 
quet  positiva  antecedentes  familiares  y  personales  tuberculosos. 

Son  cavernas  tuberculosas  de  cuerpo  cilia  e  iris  corresponden  en  enfermo  al 
tipo  clinico  de  hemorragies  juveniles  en  vitrio  de  origen  tuberculoso. 

Lesiones  de  irido-ciclitis  tuberculosa  y  glaucoma  secundario  a  la  hemor- 
ragia  en  vitrio  y  Ca'mara  anterior  algo  andlogo  (pe"rmitidme  la  comparacion) 
a  la  hemoptisis  del  tuberculoso  pulmonar  terciario. 

En  tuberculosis  pulmonar  periodo  carvernario  equivale  a  periodo  terciario 
es  el  resultado  de  la  elimination  de  los  productos  de  reblandecimiento  despue"s 
de  la  fase  de  degeneracion  caseosa. 

Caverna  ciliar. — Enorme  caverna  en  pleno  cuerpo  ciliar  llena  de  sustancias 
proteicas  grasas  y  sangre  (Fig.  8).  El  musculo  ciliar  aparece  intacto.  El 
canal  de  Schlemm  totalmente  obstruido.  Los  elementos  de  desintegracion 
celular  consecutivos  a  la  degeneracion  caseosa  de  los  focos  tuberculosos  no 
solo  llena  la  caverna  ciliar  sino  que  buscan  salida  hacia  el  vitreo. 

Existe  la  destruction  completa  de  todo  el  plexo  arterio-venoso,  la  ruptura 
de  estos  elementos  dan  lugar  a  las  hemorragias  en  vitreo  y  en  cdmara  anterior 
(Hemorragias  juveniles  de  origin  tuberculoso). 

La  caverna  estd  limitada  por  algunos  elementos  conjuntivos  y  musculares 
unidos  a  Idmina  y  a  celulas  pigmentarias. 

Como  resultado  del  proceso  inflamatorio  cronico  de  ha  formado  apoyada 
en  el  ligamento  suspensorio  del  cristalino  una  masa  que  fija  la  lente  que  ha 
sufrido  la  degeneracion  cataratosa. 

Existe  ademas  un  estado  glaucomatoso  secundario,  el  iris  pfopulsado 
contra  la  cara  posterior  de  la  cornea  ha  sufrido  tambie"n  la  degeneracion  caver- 
naria  todo  su  estroma  ha  desaparecido,  s6lo  quedan  limitando  la  ojedad  fibras 
conjuntivas  y  celulas  pigmentarias. 

El  vaciamiento  de  1  acaverna  ciliar  no  so!6  tiene  lugar  hacia  el  vitreo,  sino 
tambie"n  puede  ocurrir  en  la  cdmara  anterior,  dando  lugar  a  lo  que  clinica- 
mente  se  denomina  y  hipopion  y  los  elementos  que  lo  constituyen  dominan 
productos  de  esudacci6n  hipema,  si  la  sangre  entra  como  factor  mas  im- 
portante. 

En  nuestro  caso  el  color  pardo  del  contenido  de  la  Cdmara  anterior  nos 
hizo  pensar  en  hipema. 


224  FRANCISCO  POYALES 

El  examen  histo!6gico  de  este  globo  ocular  parece  descubrir  una  forma  de 
tuberculosis  cr6nica  que  haciendo  el  estudio  comparative  com  la  tubercu- 
losis pulconar  serfa  un  caso  de  tercer  periodo,  terminal  o  de  excavaci6n. 

Degeneraci6n  escler6sica  de  la  coroides. — En  una  zona  de  la  coroide  donde 
los  tube"rculos  no  han  sufrido  la  evoluci6n  fatal  de  la  degeneraci6n  caseosa, 
la  toxina  tuberculosa  ha  producido  el  inquistamiento  de  las  lesiones  inflama- 
torias  y  ha  determinado  la  esclerosis  total. 

La  coroide  ha  quedado  transformada  en  una  serie  de  fasticulos  fibrosos, 
aparecen  algunas  cavernarias,  es  posible  distinguir  en  lugar  de  alguna  celula 
gigante  por  la  disposici6n  conce"ntrica  de  los  elementos  fibrosos. 


JHML'^I^  A 


Fig.  8. — Enorme  caverna  en  cuerpo  ciliar. 

iEsta  Iesi6n  escler6sica  de  la  coroides  nos  permitira'  pensar  en  que  la  lo- 
calizacion  primitiva  de  la  infeccion  tuberculosa  en  este  ojo  ha  sido  en  coroides? 
Puede  ser  este  proceso  esclerosico  un  mecanismo  de  curaci6n  espontdnea. 

De  todos  modos  la  retina  sufre  intensos  transtornos  nutritivos  y  en  tem- 
peratura  que  queda  completamente  inutilizada. 

Los  dos  casos  descritos  hasta  ahora  corresponden  a  globos  oculares  con 
proceso  tuberculoso  generalizado  que  termina  con  la  vida  del  ojo  por  su 
destrucci6n  total. 

Cuando  la  lesion  se  localiza  en  un  sitio  determinado  produce  alteraciones 
que  muchas  veces  no  se  imputan  a  un  proceso  tuberculoso. 

CASO  3. — Ciclitis  tuberculosa  con  Iuxaci6n  de  cristalino  en  la  Cdmara 
anterior. 


La  Tuberculosis  Ocular  Infantil  225 

Nina  de  once  anos,  con  lesiones  tuberculosas  pulmonares — Gram  demarca- 
tion— Wassermann  negativo.  Hace  tres  afios  sufri6  un  golpe  en  el  ojo 
zquierdo  es  completamente  inutil. 

Hace  una  semana  ha  comenzado  a  sentir  fuertes  dolores  en  el  ojo. 

Al  explorarle  nos  encontramos  con  un  ojo  duro  con  signos  de  proceso  glau- 
comatoso  bastante  intense  con  perfection  luminosa  y  con  el  cristalino  luxado 
en  la  camara  anterior.  Se  le  practic6  la  enucleacion.  Estudio  histo!6gico 
del  globo  ocular.  Inclusion  en  celuidina — Coloraci6  de  los  cortes  con  Hema- 
toxilina  y  eosina. 

Dividido  el  globo  ocular  por  un  corte  antero-posterior  utilizamos  medio 
ojo  para  hacer  cortes  en  este  sentido  y  en  el  otro  medio  practicamos  cortes 
en  el  sentido  vertical  perpendiculares  al  eje  antero-posterior. 

Procesos  ciliares  y  zonula  de  Zinn.  Desde  la  ora  serrata  hasta  el  cristalino 
la  membrana  hialoid^s  se  engruesa  y  se  hace  mds  resistente. 

En  la  masa  de  este  engrosamiento  aparece  una  serie  de  fibrillas  de  natura- 
leza  elastica  que  sirven  para  fijar  el  cristalino  a  la  z6nula,  estos  elementos  se 
denominan  ligamento  suspensorio  del  cristalino. 

Estas  fibras  se  dividen  en  dos  grupos  el  m£s  abundante  vd  a  fijarse  en  la 
cristaloides  anterior,  otras  en  menor  niimero  vdn  a  insertarse  en  la  cristaloides 
posterior,  algunos  autores  aceptan  un  tipo  intermedio  de  fibras  muy  poco 
numerosas  que  se  fija  en  el  mismo  ecuador  del  cristalino. 

Esta  serie  de  fibras  descritas  se  apoyan  por  la  parte  superior  en  los  procesos 
ciliares  plegandose  exactamente  como  ellos,  constituye  un  sistema  de  ele- 
vaciones  y  depresiones. 

Esta  description  hace  comprender  como  un  proceso  ciclitico  mds  o  menos 
intenso  puede  determinar  la  ruptura  o  destruction  del  ligamento  suspensorio 
de  la  lente,  en  un  primer  periodo  se  subluxa  y  en  ultimo  se  luxa,  la  falta  el  punto 
de  apoyo  y  unido  a  esto  los  transtornos  nutritivos  determinan  la  degeneration 
cataratosa,  disminuye  de  tamano  y  libre  el  cristalino  cae  al  vitreo  o  es  posible 
atraviese  el  agujero  pupilar  como  en  nuestro  caso  y  se  coloque  en  la  camara 
anterior  obrando  como  cuerpo  extrano  y  ser  el  mecanismo  de  un  proceso 
glaucomatoso  secundario. 

Los  procesos  ciliares  han  perdido  su  disposici6n  sime'trica,  la  capa  pig- 
mentaria  su  regularidad,  marcdndose  islotes  de  pigmento,  desaparicion  com- 
pleta  de  los  espacios  pre-y-post  zonulares — No  es  posible  distinguir  la  dis- 
posici6n  radiada  de  las  fibras  de  ligamento  suspensorio. 

Cristalino  en  camara  anterior. — Por  delante  esta  en  contacto  con  la  cara 
posterior  de  la  cornea  por  detras  en  relaci6n  con  la  cara  anterior  del  iris. 

Los  procesos  de  irido-ciclitis  cr6nica  al  que  corresponde  nuestro  caso  tiene 
como  caracter  clinico  6  histologico  la  abundancia  de  exuda-dosplasticos  que 
se  depositan  en  la  cara  posterior  de  la  cornea,  de  origen  ciliar. 

En  la  formaci6n  de  estas  masas  entran  leucocitos  polinucleares — Celulas 
redondas — Hematics — Fibrina. 

15 


226 


FRANCISCO  POYALES 


La  cornea  aparece  Integra  sin  ninguna  infiltration  en  las  capas  profundas. 

No  existe  infiltraci6n  ninguna  en  la  membrana  de  Descemet,  ni  en  su 
endotelio.  El  cristalino  aparece  detr&s  del  iris  y  en  plena  degeneration  ca- 
taratosa.  El  tipo  de  catarata  en  el  momento  que  practicamos  la  enucleacion 
es  capsula — lenticular. 

La  cdpsula  anterior  del  cristalino  se  mantiene  Integra.  En  la  capa  epiterial 
existen  zonas  de  peoliteracion. 

Se  descubren  de  trecho  en'  trecho  vacuolas  de  pequeno  tamafio  llenas  de 
Ifquido  de  Morgagni  colocadas  debajo  de  la  capa  epitelial  (Fig.  9). 


Fig.  9. — Ciclitis  tuberculosa.    Luxaci6n  de  cristalino  en  la  camara  anterior. 

Mds  atras  se  encuentra  desintegracion  de  las  capas  de  la  lente,  dejando  un 
gran  espacio  lleno  de  sustancia  de  aspecto  granuloso  (esferas  de  Morgagni). 

En  el  iris  aparecen  zonas  de  intensa  inflamacion,  focos  tuberculoses 
donde  dominan  gran  cantidad  de  celulas  gigantes. 

Encima  de  la  capa  epiterial  anterior  gran  cantidad  de  exudado  a 
todo  lo  largo  de  la  superficie  del  iris  (Fig.  10) . 

En  algunos  puntos  los  exudados  se  reunen  formando  masas  de 
gran  volumen. 

El  cristalino  por  su  cara  posterior  presenta  un  marcadfsimo  re- 
pliegue  de  la  cristaloides  posterior,  esto  indica  una  reduccion  en  el 
volumen  de  la  lente  muy  marcada,  lo  que  permite  que,  destruido  el 


La  Tuberculosis  Ocular  Infantil 


227 


ligamento  suspensorio  por  el  proceso  ciclitico,  libre  la  lente  y  reducida 
de  tamano  pueda  pasar  a  traves  del  orificio  de  la  pupila  y  situarse  en 
la  camara  anterior. 

Que  consideraciones  clinicas  se  deducen  del  estudio  de  los  caso 
expuestos? 

El  valor  diagnostico  de  la  reaction  de  Pirquet  en  la  tuberculosis 
ocular  varia  segun  el  tipo  de  infection.  En  el  primer  caso  lesiones 
tuberculosas  primarias  sin  otras  manifestaciones  en  el  resto  del 
organismo  el  resultado  fue  negative. 


Fig.  10. — Iritis  tuberculosa  y  Iuxaci6n  del  cristalino  en  la  camara  anterior. 

Los  otros  dos  casos  con  las  lesiones  tuberculosas  oculares  y  en  otras 
partes  del  organismo  resultado  positive. 

Esto  procede  indicar  que  solo  tiene  valor  diagnostico  en  los  casos 
de  tuberculosis  secundaria,  pero  no  debe  dejar  de  hacerse  siempre 
que  se  sospeche  una  manifestaci6n  primaria  un  resultado  positive 
puede  ser  de  gran  valor  para  precisar  la  etiologia. 

Nosotros  hemos  empleado  la  cuti-reaccion  y  en  algunos  casos  la 
inyeccion  subcutdnea  de  tuberculosis  Koch  (O.T.)  }/£  mg.  en  nino, 
este  procedimiento  nos  parece  mas  sensible  cuando  el  estado  general 
sea  bueno  y  la  manifestation  ocular  no  sea  muy  intensa. 

No  emplearemos  nunca  la  oftalmo-reaccion. 


228  FRANCISCO  POYALES 

Como  contra  indicaciones  para  la  reaccion  de  Pirquet  nosotros 
tenemos  en  cuenta: 

1.  Historia  clinica  de  tuberculosis  positiva. 

2.  Temperaturas  frecuentes  de  37  grados  con  3. 

3.  Lesiones  de  corazon. 

4.  Hemoptisis. 

5.  Nefritis. 

6.  Epilepsia. 

Hemos  comprobado  como  una  lesion  primitiva  aislada  puede  de- 
terminar  por  propagacion  la  generalizaci6n  a  todo  el  ojo  del  proceso 
tuberculoso  sin  propagacion  al  resto  del  organismo  en  el  momento  de 
la  nucleacion  en  el  caso  1. 

El  caso  segundo  es  una  forma  de  tuberculosis  cavernaria  probable- 
mente  consecutiva  a  localizaciones  en  otra  parte  del  organismo,  este 
caso  nos  hace  pensar  que  la  tuberculosis  ocular  puede  presentar  los 
mismos  periodos  que  se  describe  en  la  tuberculosis  pulmonar. 

La  comparacion  que  hemos  hecho  entre  Hemoptisis  y  hemorragias 
en  vitreo  es  perfectamente  razonal. 

Axenfeld  y  Stock — 1909 — Fueron  los  primeros  en  fijar  el  origen 
tuberculoso  de  las  hemorragias  en  vitreo,  pues  tuvo  ocasion  obser- 
varlas  en  un  enfermo  con  antecedjsntes  familiares  y  una  iritis  tuber- 
culosa  tipica  que  mejoro  por  el  tratamiento  con  tuberculina. 

Leber,  1913,  llamo  la  atencion  como  origen  de  las  hemorragias  en 
vitreo  de  los  ninos  la  existencia  de  tuberculos  miliares  en  los  vasos 
de  la  retina. 

Fleischer,  1914,  hizo  comprobaciones  histologicas  de  alteraciones 
basculares  en  vasos  de  coroides  y  retina  en  tuberculoses  y  esto  atri- 
buye  el  origen  de  las  citadas  hemorragias. 

Nuestras  preparaciones'  nos  hacen  admitir  que  los  procesos  des- 
tructives de  iris  ciliar  y  coroides, — periodo  cavernario  que  durante 
su  evoluci6n,  o  en  momentos  determiandos,  el  contenido  de  la  cavidad 
va  a  vitreo  o  a  cdmara  anterior  simulado  una  hemorragia  olinicamente. 

El  tercer  caso  tiene  valor  en  el  capitulo  de  las  complicaciones,  la  mas 
conocida  es  el  desprendimiento  de  la  retina  cuando  existe  localizacion 
de  focos  tuberculoses  en  la  coroides.  La  luxacion  de  cristalino  que 
no  sea  de  origen  traumatico  no  debe  olvidarse  investigar  una  posible 
localizacion  tuberculosa  de  cuerpo  ciliar. 

No  he  de  fatigar  mds  vuestra  atencion,  dos  palabras  respecto  al 
problema  terapeutico. 

1.  El  ojo  conserva  agudeza  visual.     En  toda  lesion  tuberculosa 


La  Tuberculosis  Ocular  Infantil  229 

ocular  ya  sea  primaria  o  secundaria  debe  intentarse  a  toda  costa 
conservar  el  ojo  ayudando  con  un  tratamiento  general  intensive  el 
local  apropiado. 

2.  Cuando  la  tuberculizacion  del  globo  ocular  sea  tan  intensa  que 
la  funcion  visual  este  completamente  abolida,  y  de  examen  clinico 
saquemos  como  consecuencia  la  perdida  irreparable  producida  por  las 
lesiones,  el  ojo  debe  ser  enucleado  como  medio  profildctico  y  terapeu- 
tico. 

DISCUSSION 

DB.  WILLIAM  C.  FINNOFF  (Denver,  Col.) :  Tuberculosis  of  the  eye  undoubt- 
edly exists  more  often  than  is  commonly  supposed.  The  chief  reason  for  our 
failure  to  recognize  this,  as  has  been  pointed  out  by  Dr.  Poyales,  is  the 
paucity  of  material  that  has  been  saved  for  microscopic  examination. 

Tuberculosis  of  the  eye  in  children  is  not  seen  frequently,  but  the  disease 
is  not  rare,  and  a  number  of  cases  have  been  reported  in  the  literature  in 
recent  years.  The  chronic  type  of  keratoscleritis  associated  with  uveitis  is 
probably  the  most  common  form.  In  many  instances  the  greatest  involve- 
ment in  these  cases  is  in  the  anterior  segment  of  the  globe.  In  this  variety  of 
tuberculosis  the  subject  is  frequently  robust  and  apparently  in  good  health, 
and  no  positive  lesions  are  found  elsewhere  in  the  body  by  our  present  known 
methods  of  examination,  including  the  x-ray.  A  positive  von  Pirquet  reac- 
tion suggests  the  cause,  but  is  not  positively  diagnostic  as  far  as  the  eye  con- 
dition is  concerned.  The  focal  reactions  in  the  eye  are  positive,  and  sub- 
cutaneous injections  of  tuberculin  (preferably  0.  T.)  are  our  only  means  of 
diagnosis.  This,  of  course,  is  not  to  be  considered  in  case  of  active  tubercu- 
losis elsewhere  in  the  body. 

The  two  cases  which  Dr.  Poyales  has  reported,  in  which  there  is  a  definite 
history  of  trauma  preceding  the  tuberculosis  of  the  eye,  are  of  interest  because 
we  think  of  trauma  as  an  underlying  factor  in  the  production  of  tuberculosis  of 
the  eye  in  tuberculous  subjects — that  trauma  makes  the  soil  fertile  for  the 
tubercle  bacillus.  In  some  experiments  we  have  been  carrying  out  on  animals 
it  has  been  rather  striking  to  find  that  trauma  plays  a  very  small  part  in  the 
course  of  tuberculosis.  Eyes  that  are  not  traumatized  run  practically  the 
same  clinical  course  as  traumatized  eyes  in  animals  that  have  been  inoculated 
with  tubercle  bacilli. 

The  classification  of  tuberculosis  of  the  eye  as  primary  where  there  is  no 
lesion  found  elsewhere  in  the  body  I  believe  is  often  erroneous,  unless  the 
tuberculosis  exists  in  a  portion  of  the  eye  which  is  either  directly  or  indirectly 
exposed  to  the  air — other  than  eyes  that  have  been  perforated.  The  intra- 
ocular tuberculosis  that  has  been  in  the  past  classified  as  primary,  in  which 
the  parts  were  not  exposed  to  the  air  and  not  perforated,  I  believe  is  secondary 
in  most  instances,  the  primary  focus  being  elsewhere  in  the  body  but  not  dis- 
covered. These  cases  I  think  should  be  classified  as  secondary  tuberculosis. 

MB.  J.  GBAY  CLEGG  (Manchester,  England) :  I  want  to  mention  one  case. 
Leprosy,  as  we  are  aware,  is  now  being  treated  with  Chaulmoogra  oil  and 


230  FRANCISCO  POYALES 

preparations  therefrom.  I  have  been  using  injections  of  sodium  morrhuate 
in  the  treatment  of  ocular  tuberculosis,  and  I  am  convinced  that  it  is  worth 
trying,  for  in  one  case  a  large  number  of  tubercles  rapidly  disappeared. 

The  case  I  wish  to  mention  is  that  of  a  baby  who  was  brought  to  me  by 
the  family  doctor  with  a  diagnosis  of  iritis.  Undoubtedly  there  were  signs  of 
that  disease,  but  there  was  in  the  iris  a  small  mass  exactly  resembling  a 
tuberculous  nodule.  I  had  the  case  go  to  a  clinical  pathologist,  Dr.  Arnold 
Renshaw,  who  found  that  the  Wassermann  reaction  was  positive  in  the  child 
and  the  mother.  Under  appropriate  treatment  the  condition  cleared  up.  So 
it  is  possible  for  us  sometimes  to  confuse  our  cases  of  syphilitic  infection  of  the 
eye  with  those  of  tuberculosis. 

DR.  IGNACIO  BARRAQUER  (Barcelona,  Spain):  No  quiero  hablar  ni  del 
diagnostico  ni  del  tratamiento  de  todas  las  formas  de  la  tuberculosis  ocular; 
unicamente  quiero  llamar  vuestra  atencion  sobre  un  grupo  de  enfermos  que 
todos  vemos  a  diario  con  vitreo  turbio,  sinequias,  descemetitis,  ataques  de 
glaucoma  secundario,  etc.,  etc.,  enfermos  que  diagnosticamos  de  iridociclitis 
idiopatica  o  de  la  menopausia  porque  ni  el  analisis  general  del  enfermo  ni 
los  analisis  de  laboratorio  nos  ayudan  a  descubrir  la  etiologia  que  pueda 
orientarnos  en  el  tratamiento.  En  algunos  de  estos  enfermos  el  examen  mic- 
roscopico  del  ojo  vivo  por  medio  del  cristal  de  contacto,  nos  hace  descubrir 
pequenos  focos  de  periflebitis  retinal,  acumulos  de  linfocitos  en  el  vitreo, 
exudados  gelatinosos  de  forma  esferica  detras  del  iris  que  forman  sinequias, 
precipitaciones  en  la  cara  posterior  de  la  cornea,  grandes,  transparentes, 
hemiesfericas,  gelatinosas  y  entre  ellas  grupos  de  forma  estrellada  de  lin- 
facitos.  Ellos  mejoran  y  curan  rapidamente  por  medio  del  tratamiento  foto- 
terapico  y  de  las  tuberculinas. 

DR.  H.  H.  STARK  (El  Paso,  Texas) :  According  to  the  opinion  of  practition- 
ers in  general,  all  of  the  civilized  race  pass  through  a  stage  of  tuberculosis 
before  the  age  of  puberty,  and  we  are  therefore  confronted  with  the  problem 
of  each  child  having  had  at  some  time  in  his  life  tuberculosis,  practically 
untreated.  I  do  not  believe  it  is  well  to  declare  a  case  negative  on  a  negative 
von  Pirquet.  I  believe  in  the  specificity  of  old  tuberculin  and  the  focal  reac- 
tions. 

The  two  cases  reported  with  trauma  emphasize  the  fact  that  traumatized 
tissue,  whether  it  be  eye  or  any  other  tissue  of  the  body,  is  always  subject  to 
tuberculosis.  The  extent  of  injury  necessary  to  produce  tuberculosis  is  un- 
known. It  is  quite  possible  that  the  strain  occurring  in  a  case  of  hypermetropia 
may  produce  it. 

DR.  JOHN  E.  WEEKS  (New  York  City) :  We  must  never  lose  sight  of  the 
fact  that  tuberculosis  and  syphilis  may  exist  in  the  same  individual  at  the 
same  time,  and  that  it  is  desirable  to  make  the  necessary  tests  to  determine 
the  presence  or  absence  of  both  in  all  cases  of  suspected  tuberculosis. 
The  diagnosis  of  a  tuberculous  lesion  in  my  opinion  depends  on  the  produc- 
tion of  a  local  reaction  by  the  introduction  of  tuberculin  into  the  system, 
preferably  old  tuberculin  hypodermically.  I  do  not  think  the  von  Pirquet  test 
is  of  any  value  in  cases  of  this  kind  except  as  it  may  give  information  regarding 


La  Tuberculosis  Ocular  Infantil  231 

a  general  tuberculosis.  So  far  as  lesions  of  the  eye  are  concerned,  unless 
the  reaction  in  the  eye  is  occasioned  by  the  introduction  of  tuberculin  into  the 
system,  we  are  not  sure  that  the  lesion  is  tuberculous.  The  presence  of  tuber- 
culosis in  the  system  in  general  frequently  cannot  be  determined  by  any 
physical  examination,  but  only  by  the  use  of  tuberculin.  X-ray  examinations 
are  often  of  much  value,  but  are  not  positive  in  all  cases. 

Tuberculosis  in  my  opinion  is  primary  in  the  eye  only  in  those  cases  where 
the  anterior  portion  of  the  globe  is  affected — in  other  words,  where  the 
tubercle  bacillus  can  be  carried  into  the  tissues  of  the  eye  by  trauma.  In  all 
cases  of  tuberculosis  affecting  the  posterior  part  of  the  eye  the  condition  is 
secondary. 

In  regard  to  the  treatment  of  tuberculosis  of  the  eye,  it  seems  to  me  that 
the  most  efficacious  treatment  (which  should  be  employed  only  in  those  cases 
where  a  profound  general  tuberculosis  is  not  present)  is  by  means  of  tu- 
berculin given  in  sufficient  dosage  to  affect  the  individual  just  short  of  a 
general  reaction.  Tuberculin  therapeusis  by  means  of  minute  doses  given  in 
the  treatment  of  tuberculosis  of  the  eye  is  in  my  opinion  often  absolutely 
valueless.  If  the  dose  is  carried  out  as  I  have  suggested,  just  short  of  the 
point  of  general  reaction,  and  given  every  four  or  five  days,  as  the  case  may 
be,  the  best  possible  results  will  be  obtained ;  but  the  treatment  must  be 
continued  for  some  months  after  the  manifestations  have  apparently  subsided 
to  insure  against  recurrence.  We  all  know  that  recurrences  take  place,  and 
these  recurrences  are  more  frequent  in  tuberculosis  of  the  choroid  than  in 
tuberculosis  of  the  anterior  segment  of  the  globe,  although  recurrences  in 
corneal  and  scleral  tuberculosis  are  not  infrequent. 

MR.  E.  TREACHER  COLLINS  (London,  England):  The  question  has  been 
raised  as  to  whether  the  tuberculosis  we  meet  with  in  the  eye  is  primary  or 
secondary.  I  am  strongly  of  the  opinion  that,  in  a  vast  majority  of  cases  of 
tuberculosis  of  the  eye,  it  is  secondary.  I  think  unless  the  tubercle  is  inserted 
into  the  eye  through  a  perforating  injury  we  may  always  regard  it  as  a  second- 
ary lesion.  It  seems  to  me  almost  inconceivable  that  tubercle  bacilli  could 
gain  entrance  into  the  system  without  any  manifestations  at  the  point  of 
entrance,  and  then  circulate  until  they  came  to  the  vessels  of  the  eye  before 
they  caused  any  foci  of  inflammation.  I  have  some  rather  definite  proof  in 
connection  with  this  matter.  Many  years  ago,  when  first  tuberculin  was 
brought  before  the  profession  by  Professor  Koch,  I  saw  a  case  similar  to  those 
reported  by  the  writer  of  this  paper,  i.  e.,  one  of  tubercle  nodules  of  the  eye  in 
a  young  subject,  and  we  gave  an  injection  of  Koch's  tuberculin  and  got  a  very 
marked  local  and  general  reaction.  So  marked  was  the  local  reaction  that 
the  eye  became  painful  and  enucleation  was  performed.  Apparently  the 
child  was  otherwise  in  good  health,  and  showed  no  manifestations  of  tuber- 
culosis that  could  be  detected  clinically.  A  month  or  so  after  enucleation  of 
the  eye  a  second  injection  of  Koch's  tuberculin  was  administered,  and  we 
again  got  a  very  marked  general  reaction,  which  definitely  showed  that  there 
must  still  have  been  some  other  lesion  in  the  body  from  which  the  eye  prob- 
ably became  infected.  It  is  an  important  point,  I  think,  in  the  treatment. 
If  we  regard  the  eye  as  the  primary  source  of  trouble  we  would  be  more 


232  FRANCISCO  POYALES 

inclined  to  enucleate  the  eye  than  if  it  were  secondary.  I  do  not  think  we 
ought  to  enucleate  an  eye  for  tuberculosis  unless  it  is  thoroughly  disorganized 
as  a  seeing  organ. 

I  have  cut  sections  of  a  good  number  in  cases  of  tuberculosis  of  the  eye  in 
young  subjects.  I  am  not  quite  in  agreement  with  some  of  the  other  speakers 
that  the  tubercle  is  most  common  in  the  anterior  part  of  the  eye.  I  believe  a 
large  number  of  cases  of  localized,  old  choroidal  atrophy  that  we  see  in  children 
are  obsolescent  tubercular  particles.  Dr.  Sydney  Stephenson  brought  for- 
ward some  evidence  on  this  point  a  few  years  ago. 

A  favorite  site  for  the  commencement  of  tuberculosis  of  the  eye  is  in  the 
lymph-spaces  between  the  ciliary  body  and  the  sclera.  In  several  cases  I 
have  examined  microscopically  I  found  nodules  situated  externally  to  the 
ciliary  muscle.  That  accounts  for  the  early  symptoms  which  we  find  in 
these  cases  of  scleritis.  Many  of  the  cases  begin  as  patches  of  scleritis  which 
afterward  extend  into  the  cornea,  so  that  we  get  a  sclerosing  keratitis.  If  we 
follow  these  cases  we  find  that  later  the  spaces  of  Fontana  become  involved 
in  the  mass  of  tubercle,  and  then  tubercles  may  appear  in  the  iris  at  the  per- 
iphery of  the  anterior  chamber;  or  the  tubercular  mass  may  extend  through 
external  to  the  ciliary  muscle,  invading  the  ciliary  processes  and  giving  rise  to 
diminution  of  tension.  Elastic  tissues  are  exceedingly  liable  to  melt  when 
tubercles  come  into  contact  with  them.  This  is  seen  in  the  lungs,  and  also  in 
the  tissues  of  the  eye.  The  capsule  of  the  lens  is  easily  destroyed  when  the 
tubercle  mass  presses  upon  it,  and  also  Descemet's  membrane. 

With  regard  to  the  treatment  of  tubercular  lesions,  I  have  had  some 
encouraging  results  from  the  use  of  tuberculin.  Tubercles  in  the  anterior 
part  of  the  eye  are  sometimes  seen  to  dissolve  by  the  use  of  tuberculin  injec- 
tions. There  is  great  difficulty  in  fixing  the  amount  of  the  dose  which  it  is 
wise  to  use  in  these  cases.  I  quite  agree  with  Dr.  Weeks  that  tuberculin 
should  be  used  only  where  there  is  no  indication  of  phthisis.  Where  the 
tubercular  lesion  is  localized  I  do  not  think  we  need  fear  the  use  of  tuberculin. 
I  think  it  is  wiser,  however,  to  begin  with  small  doses  and  gradually  work 
up,  as  we  do  not  know  how  each  patient  will  react  to  tuberculin.  I  think 
large  doses  are  often  required,  but  I  prefer  to  work  up  gradually.  Under 
such  treatment  the  tubercles  may  disappear  from  the  eye  in  a  satisfactory 
way,  but  if  you  watch  the  cases  for  some  years  afterward  it  will  be  observed 
that  the  tubercle  is  liable  to  recur. 

DR.  F.  H.  VERHOEFF  (Boston,  Mass.):  Personally,  I  have  never  seen 
chronic  ocular  tuberculosis  in  an  infant,  and  I  notice  that  this  paper  does  not 
really  refer  to  infants,  but  to  children.  I  have  seen  it  in  children  occa- 
sionally. I  have  a  child  about  three  years  old  under  my  care  now  with 
tuberculosis  of  the  ciliary  body  and  tubercles  on  the  iris  and  in  the  filtration 
angle. 

In  regard  to  tuberculosis  of  the  anterior  part  of  the  eye,  my  interpretation 
of  what  we  find  there  is  somewhat  different  from  that  of  Mr.  Collins.  He 
says  that  he  most  commonly  finds  tubercles  between  the  ciliary  body  and  the 
sclera.  He  does  not  say  how  they  get  there,  but  he  evidently  assumes  that 
they  represent  direct  metastases  through  the  blood.  Some  years  ago  I  made 


La  Tuberculosis  Ocular  Infantil  233 

some  experiments  in  an  attempt  to  show  just  how  and  where  the  lesions  in 
anterior  tuberculosis  occur.  Of  course,  in  experimenting  with  animals,  if 
you  introduce  virulent  tubercle  bacilli  into  the  eye  the  tuberculosis  is  so 
violent  that  it  is  not  comparable  to  that  of  human  individuals.  In  order  to 
find  out,  therefore,  just  where  the  tubercle  bacilli  would  naturally  lodge  I 
employed  dead  bacilli.  I  injected  them  into  the  vitreous  and  the  aqueous 
humor.  In  these  rabbits  I  found  the  lesions  occurred  just  where  they  do  in 
human  beings.  Inject  the  bacilli  into  the  vitreous  and  you  will  get  tubercles 
on  the  iris  or  ciliary  body,  and  you  may  get  tubercles  in  the  vitreous,  but  the 
most  frequent  place  is  at  the  filtration  angle,  and  from  there  they  may  go 
back  to  the  subchoroidal  space.  In  most  cases  the  bacilli  extend  along  the 
veins  leading  from  the  filtration  angle,  producing  scleritis,  and  you  may  even 
produce  tubercles  immediately  underneath  the  conjunctiva  of  the  limbus. 

In  regard  to  whether  tuberculosis  in  the  human  subject  is  primary  or  not,  of 
course  we  naturally  presume  that  it  is  not  primary,  but  we  shall  not  know 
certainly  as  to  this  until  we  have  a  good  many  autopsies.  Patients  with 
chronic  ocular  tuberculosis,  however,  practically  never  die  of  tuberculosis. 
Some  years  ago  I  did  an  autopsy  in  one  of  these  cases  and  found  that  the 
woman  had  died  as  the  result  of  tuberculosis  of  the  pituitary  body.  The 
primary  lesion  in  that  case  was  a  small  lesion  at  the  base  of  the  lung,  some- 
thing that  could  not  have  been  detected  during  life. 

DR.  RICHARD  KERRY  (Montreal,  Canada) :  There  is  one  aspect  of  tuber- 
culosis of  the  eye  which  requires  more  attention  than  it  has  received  and  that 
is,  that  it  occurs  in  two  definite  clinical  forms.  The  one,  characterized  by 
tubercle  formation,  which  tends  to  progress  to  panophthalmitis,  with  destruc- 
tion of  the  eyeball;  in  the  other  the  formation  of  tubercle  is  not  so  obvious, 
but  there  is  a  gummatous  exudate  which  tends  to  organize,  the  most  usual 
result  being  loss  of  sight  with  preservation  of  the  eyeball.  So  far  as  I  am 
aware  the  relationship  of  these  two  forms  to  one  another  has  not  been  estab- 
lished, but  urgently  demands  investigation.  There  may  be  some  question 
as  to  how  far  the  fibrous  type  is  tuberculous,  it  occurs,  however,  practically 
always  in  members  of  tuberculous  families  and  there  is  usually  other  evidence 
of  tuberculosis  in  the  patient. 

As  to  treatment:  We  have  had  a  number  of  unusual  results  with  hypo- 
dermic injections  of  iodin.  In  my  series  I  have  lost  only  one  eyeball,  and  in 
that  case  treatment  was  withdrawn  during  the  critical  period  of  the  disease. 
The  treatment  is  in  no  sense  specific  but  acts  by  raising  the  resisting  power  of 
the  body.  In  a  case  recently  reported  by  Dr.  Louie  Stegman,  of  Battle  Creek, 
Mich.,  an  increase  of  no  less  than  40%  in  leukocytosis,  after  the  fourth  dose, 
was  reported,  thus  demonstrating  a  rational  basis  for  the  action  of  the  drug. 

DR:  F.  POYALES  (closing) :  I  wish  to  thank  the  members  who  have  taken 
part  in  this  discussion.  I  believe  that  anatomic-pathologic  examinations 
should  be  done  more  frequently,  and  that  many  times  a  tubercular  origin 
would  be  found  to  explain  many  secondary  ocular  lesions. 


ENDOPHTHALMITIS  PHACOANAPHYLACTICA 

F.  H.  VERHOEFF,  M.D.,  AND  A.  N.  LEMOINE,  M.D. 

(From  the  Massachusetts  Charitable  Eye  and  Ear  Infirmary  and 

Harvard  Medical  School) 

Boston,  Mass. 

Uhlenhuth,1  in  1903,  showed  that  rabbits  could  be  immunized  by 
repeated  intravenous  injections  of  ox  lens  protein,  so  that  the  blood 
would  give  the  precipitin  reaction  with  lens  protein  from  any  animal 
source.  He  further  showed  that  these  immunized  animals  failed  to 
give  the  reaction  with  ox  serum.  In  other  words,  the  reaction  was 
tissue  specific  and  not  species  specific.  In  1908  Krauss,  Doerr,  and 
Sohma2  showed  that  rabbits  could  be  sensitized  by  single  injections 
of  the  lens  protein  of  various  animals,  so  that  they  would  give  fatal 
anaphylactic  reactions  to  the  lens  protein  from  any  animal  source, 
and  they  also  found  that  this  reaction  was  likewise  tissue  specific. 
In  1909  Uhlenhuth  and  Haendel3  showed  that  guinea-pigs  could  even 
be  sensitized  to  their  own  lens  protein.  These  results  have  since  been 
verified  by  other  observers.4 

So  far  as  we  know,  no  experiments  have  hitherto  been  made  re- 
lating to  the  possibility  that  ocular  inflammations  may  result  from 
injury  to  the  lens  in  sensitized  animals,  nor  have  any  observations 
been  recorded  that  would  indicate  that  certain  human  individuals 
are  hypersensitive  to  lens  protein. 

It  is,  of  course,  a  well-known  fact  that  after  injuries  to  the  lens, 
traumatic  or  operative,  in  some  cases  inflammatory  reaction  of  greater 
or  less  severity  follows,  while  in  others  no  such  reaction  takes  place. 
Some  ophthalmic  surgeons  have  maintained  that  this  inflammatory 
reaction  was  always  due  to  infection;  others  have  regarded  it  as  the 
result  of  irritation  due  to  lens  matter.  The  latter  view  was  appar- 
ently first  brought  forward  by  Lagrange  and  Lacoste5  in  1911,  who 
reported  eight  cases  in  a  series  of  100  cataract  extractions.  Schirmer6 
previously  (1899)  had  observed  a  series  of  cases  presenting  the  same 
clinical  picture  in  which  he  had  found  the  aqueous  sterile,  but  which 
he  did  not  explain  on  the  basis  of  irritation  from  lens  matter.  More 
recently  the  view  that  lens  matter  may  cause  intraocular  inflammation 

234 


Endophthalmitis  Phacoanaphylactica  235 

has  been  elaborated  by  Straub,7  who  has  reported  the  clinical  and 
microscopic  findings  in  a  number  of  cases  of  such  inflammation  which 
he  has  termed  "  Endophthalmia  Phakogenetica."  He  did  not  con- 
sider the  possibility  that  some  individuals  are  more  sensitive  to  lens 
protein  than  others,  but  regarded  the  inflammation  as  due  to  special 
toxicity  on  the  part  of  the  lens,  and  maintained  that  this  toxicity 
increased  with  age.  He  did,  however,  attempt  to  immunize  one 
patient  with  such  an  inflammatory  cdndition  by  subcutaneous  in- 
jections of  lens  protein. 

It  occurred  to  one  of  us  that  inflammatory  reaction  following  injury 
to  the  lens  in  certain  individuals  might  depend  upon  hypersensitive- 
ness  to  lens  protein,  acquired  or  congenital,  in  these  individuals,  and 
its  absence  to  the  lack  of  such  hypersensitiveness.  We  have  en- 
deavored to  test  this  hypothesis  by  clinical  and  pathologic  observa- 
tions and  by  animal  experimentation. 

To  ascertain  whether  or  not  individuals  are  hypersensitive  to  lens 
protein  we  have  employed  the  dermal  and  intradermal  tests  commonly 
used  for  determining  sensitiveness  to  foreign  proteins.  In  all  cases 
pig  lenses  wrere  used  for  the  tests,  and,  in  some  of  them,  in  addition, 
human  lenses  obtained  at  cataract  operations  and  ox  lenses.  The 
lenses  were  obtained  under  aseptic  precautions,  and,  after  removing 
their  capsules,  dried  in  the  air  for  twenty-four  to  forty-eight  hours, 
and  ground  to  a  powder  in  a  mortar  with  a  pestle. 

The  dermal  tests  were  made  by  scarifying  the  skin  of  the  forearm 
with  a  v.  Pirquet  scarifier  until  serum  exuded  without  blood,  and 
then  placing  the  lens  powder  on  the  scarified  area  and  keeping  it 
moist  with  normal  salt  solution  for  about  twenty  minutes.  Controls 
were  made  with  salt  solution  only.  Positive  reactions  became  ob- 
servable usually  in  fifteen  to  sixty  minutes,  and  consisted  in  slight 
hyperemia  and  elevation  of  the  area.  One  patient  (Case  1)  had  a 
very  irritable  skin,  so  that  the  control  area  also  showed  considerable 
reaction,  but  the  area  treated  with  lens  protein  showed  so  much 
greater  reaction  that  there  was  no  doubt  that  the  test  was  positive. 

In  the  intradermal  test  we  used  a  10  per  cent,  solution  by  weight 
of  fresh  lens  in  normal  saline  solution,  to  which  0.5  per  cent,  phenol 
was  added,  0.04  c.c.  being  injected  between  the  layers  of  the  skin. 
For  the  control,  normal  saline  solution  containing  0.5  per  cent,  phenol 
was  used.  A  positive  reaction  consisted  in  elevation  of  the  area  and 
hyperemia  around  it.  This  was  usually  not  definite  in  less  than  two 
hours,  and  sometimes  not  until  about  twenty-four  hours.  This  test 


236  F.  H.  VERHOEFF  AND  A.  N.  LEMOINE 

proved  to  be  the  more  satisfactory  of  the  two,  since  it  was  always 
positive  when  the  dermal  test  was  positive,  and  definitely  positive 
when  the  latter  was  only  slightly  so.  In  some  of  our  more  recent 
cases  we  have  used  three  graded  dilutions  in  making  the  intradermal 
tests. 

By  means  of  these  tests  we  have  attempted  first  to  ascertain 
whether  patients  who  have  had  intraocular  inflammation  apparently 
due  to  rupture  of  the  lens  capsule  are  actually  sensitive  to  lens  pro- 
tein. Naturally,  only  a  few  such  patients  were  available  to  us  for 
this  purpose,  but,  fortunately,  these  few  were  exceptionally  suitable. 
Cases  2,  3,  and  4  were  selected  previously  on  the  basis  of  microscopic 
examinations,  the  patients  on  request  returning  for  the  skin  tests. 
The  clinical  records  of  these  cases,  however,  were  later  found  to  accord 
with  the  microscopic  findings.  In  each  case  the  results  of  the  tests 
were  positive. 

Following  are  the  cases  of  this  series,  twelve  in  number,  in  which 
these  tests  were  made : 

CASE  1. — Contusion  of  right  eye  with  rupture  of  lens  capsule,  followed  by 
iridocyclitis.  Enucleation  and  microscopic  examination  of  right  eye.  Later, 
iritis  and  glaucoma  in  cataractous  left  eye.  Iridectomy.  Cataract  extrac- 
tion. Rupture  of  lens  capsule  found  at  operation.  Dermal  and  intradermal 
tests  with  lens  protein  positive. 

Thomas  S.,  aged  fifty-three,  was  struck  in  the  right  eye  by  the  end  of  a 
lever,  April,  1919.  No  perforation  of  globe.  Eye  became  inflamed,  but  pa- 
tient continued  to  work  for  four  months.  First  seen  at  the  Massachusetts 
Charitable  Eye  and  Ear  Infirmary,  Out-patient  Department,  February  4, 
1920.  At  this  time  the  lens  was  opaque,  there  was  posterior  synechia  below, 
and  a  low-grade  iritis.  Light  projection  good.  Patient  advised  to  have  teeth 
extracted,  which  he  did.  April  7, 1920,  admitted  to  wards.  Pain  in  right  eye. 
X-ray  examination  for  foreign  body  negative.  On  examination  the  cornea  was 
clear,  there  were  posterior  synechia,  slight  hypopyon,  and  marked  ciliary  con- 
gestion. The  lens  showed  a  mottled,  milky  appearance.  Light  projection  was 
faulty.  The  left  eye  showed  an  immature  cataract,  reducing  vision  to  20  /100. 
Complete  physical  examination  made  at  the  Massachusetts  General  Hospital 
and  Wassermann  tests  were  negative. 

June  3,  1920:  The  condition  of  the  right  eye  showed  no  improvement  and 
the  eye  was  removed. 

March  20,  1921:  Patient 'readmitted  to  wards  complaining  of  increasing 
pain  in  the  left  eye,  which  he  had  had  for  three  or  four  weeks.  On  examina- 
tion there  were  found  marked  ciliary  congestion,  cornea  steamy,  anterior 


Endophthalmitis  Phacoanaphylactica  237 

chamber  normal  depth,  pupil  contracted,  irregular  and  inactive,  lens  diffusely 
opaque.  Tension  +  1. 

March  29:  Iridectomy,  0.  S. 

April  7:  Tension  24  mm.  (Souter.) 

April  16:  Tension  16  mm.  (Souter)  (pilocarpin). 

April  29:  Small  hypopyon.    ^f-ray  of  sinuses  negative. 

May  8:  Considerable  congestion.    Descemetitis  marked. 

May  10:  Paracentesis. 

May  13  to  June  10:  Course  of  13  doses  of  Coley's  toxins  given,  with  a 
temperature  of  103.2°  F.  and  leukocytosis  of  18,000  at  one  time  under  this 
treatment. 

June  16:  Dr.  Verhoeff,  concluding  that  the  condition  was  due  to  lens  mat- 
ter, attempted  an  intracapsular  extraction.  At  operation  the  capsule  was 
found  ruptured,  so  that  it  could  not  be  grasped  with  capsule  forceps  and  an 
ordinary  extraction  was  necessary.  As  much  cortical  matter  as  possible  was 
removed  by  irrigation. 

June  24:  Eye  white.    No  anterior  chamber.    Counts  fingers  at  one  foot. 

July  14:  Operation.  Iris  first  separated  from  cornea  and  an  iridotomy  per- 
formed. 

July  15:   Good  anterior  chamber.    Very  little  reaction. 

July  20:  Dermal  test  with  dried  pig  lens  positive. 

August  3 :  Eye  quiet,  but  opening  in  iris  closing.  Cornea  cloudy  through- 
out, but  relatively  clear  in  the  center.  Vascularization  of  cornea  at  periphery. 
Good  anterior  chamber.  Vision:  light  perception,  projection  good. 

August  16:  Intradermal  test  with  pig  lens  markedly  positive. 

August  18:  Dermal  tests  with  ox  lens  and  immature  human  cataract  both 
positive.  Also  dermal  tests  with  cortical  matter  from  mature  cataract  and 
nucleus  from  same  cataract  moderately  positive. 

September  13:  Iridotomy. 

October  20:  Eye  has  gradually  improved.  Now  white  and  quiet.  Cornea 
much  clearer.  Iridotomy  opening  remains  patent.  Vision:  Counts  fingers 
at  six  inches. 

PATHOLOGIC  EXAMINATION 

(4079)  Right  eye:  Fixation  in  10  per  cent,  formalin,  followed  by  acid 
alcohol  (Figs.  1  and  2). 

The  cornea  shows  very  slight  infiltration  with  pus-cells  in  the  posterior 
layers  and  beginning  vascularization  at  the  periphery,  some  of  the  vessels 
extending  for  a  distance  of  2  mm.  anterior  to  the  canal  of  Schlemm.  The 
epithelium  and  Bowman's  membrane  are  intact.  No  wound  of  the  cornea  is 
to  be  found.  The  tissues  of  the  limbus  and  the  episclera,  extending  as  far 
back  as  the  equator,  are  infiltrated  with  lymphoid  and  plasma  cells.  The 
endothelium  of  the  cornea  is  absent  in  places  behind  the  center,  but  is  intact 
at  the  periphery.  Attached  to  the  endothelium  are  numerous  cells  consisting 


238 


F.  H.  VERHOEFF  AND  A.  N.  LEMOINE 


Fig.  1,  Case  1. — Showing  rupture  in  lens  capsule.  The  gap  is  covered  by 
pupillary  membrane  which  is  coated  on  its  inner  surface  by  endothelial  phagocytes. 
Beneath  this  the  lens  is  densely  infiltrated  with  pus-cells,  many  of  which  are 
necrotic.  (Photo  X  25.) 


Fig.  2,  Case  1. — Showing  destruction  of  pigment  layer  of  iris  and  infiltrate 
extending  from  iris  stroma  into  lens.  E,  Layer  of  endothelial  phagocytes.  P, 
Massive  layer  of  necrotic  pus-cells.  Note  precipitates  on  posterior  surface  of 
cornea.  (Photo  X  20.) 


Endophthalmitis  Phacoanaphylactica  239 

chiefly  of  lymphocytes,  and  large  mononuclear  cells,  with  here  and  there  pus- 
cells.  Over  long  stretches  these  cells  form  a  layer  one  to  three  times  the  thick- 
ness of  Descemet's  membrane.  Rarely  the  cells  are  agglutinated  into  small 
clumps.  The  ligamentum  pectinatum  is  infiltrated  with  similar  cells.  The 
nitration  angle  is  open. 

The  iris  is  adherent  to  the  lens  by  a  wide  posterior  synechia.  It  is  markedly 
infiltrated  with  plasma  cells,  and  near  the  pupil  it  shows  nodular  collections  of 
lymphocytes.  The  pupil  is  1.75  mm.  in  diameter.  A  pupillary  membrane 
continues  from  the  posterior  synechia  over  the  surface  of  the  lens.  Attached 
to  the  anterior  surface  of  the  iris  is  a  thin  layer  composed  chiefly  of  lym- 
phocytes, which  are  occasionally  agglutinated  into  small  clumps.  Some  sec- 
tions show  the  pigment  epithelium  of  the  iris  destroyed  and  the  infiltrate 
extending  through  the  pupillary  membrane  into  the  lens.  The  pupillary  mem- 
brane is  still  in  active  formation  and  is  rich  in  fibroblasts.  It  contains  also 
numerous  endothelial  leukocytes  and  occasionally  giant-cells  of  the  Langhans 
type1,  some  of  which  are  pigmented.  Numerous  pigmented  cells  are  present 
throughout  the  membrane,  but  are  particularly  abundant  where  the  pigment 
epithelium  has  been  broken  through. 

The  lens  capsule  shows  a  defect  2  mm.  in  diameter.  This  defect  begins  on 
the  temporal  side  of  the  pupil,  most  of  it  being  behind  the  iris.  The  anterior 
capsule  is  swollen  in  places  to  about  twice  its  normal  thickness  and  in  other 
places  thinned.  At  the  margin  of  the  defect  it  is  swollen  and  split  into  two 
layers,  the  cleft  being  invaded  by  inflammatory  cells.  The  defect  is  covered 
by  a  continuation  of  the  pupillary  membrane.  This  membrane  also  continues 
in  attenuated  form  over  the  capsule  to  the  equator,  and  in  some  places  around 
it  for  a  short  distance  upon  the  posterior  capsule.  The  endothelial  leukocytes 
and  giant-cells  are  especially  abundant  over  the  defect  in  the  capsule.  Be- 
tween the  membrane  and  the  lens  substance  there  is  a  thick  layer  consisting 
chiefly  of  pus-cells,  which  also  extends  beneath  the  capsule  on  each  side.  Be- 
neath the  capsule  most  of  the  pus-cells  show  marked  necrosis.  Where  they 
have  extended  into  clefts  within  the  lens  substance,  necrosis  is  complete.  At 
one  place,  a  considerable  distance  from  the  defect,  the  capsule  is  greatly 
thinned,  apparently  by  the  eroding  action  of  the  cells  attached  to  its  outer 
surface,  which  here  almost  completely  perforate  it.  The  lens  cortex  presents 
marked  cataractous  changes  throughout,  showing  numerous  spaces  and  clefts 
filled  with  hyaline  balls.  At  the  equator  there  are  numerous  bladder  cells. 
The  lens  nucleus,  except  for  a  few  vacuoles,  is  practically  normal.  The  pupil- 
lary membrane  has  extended  between  the  capsule  and  the  lens  substance,  on 
one  side  to  the  equator,  on  the  other  side  about  one-fourth  of  this  distance, 
destroying  the  capsular  epithelium.  The  capsular  epithelium  has  not  ex- 
tended beneath  the  posterior  capsule  except  for  a  short  distance  at  the 
periphery,  where,  in  places,  it  has  proliferated  and  formed  a  thin  capsular 
cataract. 


240  F.  H.  VERHOEFF  AND  A.  N.  LEMOINE 

The  ciliary  body  is  comparatively  normal.  From  its  surface,  particularly 
from  that  of  the  orbiculus  ciliaris,  is  being  given  off  a  moderate  number  of 
lymphocytes  and  a  large  number  of  mononuclear  cells.  At  the  ora  serrata 
cyclitic  membranes  are  in  the  process  of  formation.  The  anterior  part  of  the 
vitreous  contains  an  increased  number  of  stellate  cells  and  large  and  small 
mononuclear  cells.  The  latter  are  collected  in  considerable  numbers  also  on 
the  posterior  surface  of  the  lens  capsule. 

The  optic  disc  is  definitely  swollen,  and  some  of  its  veins  show  perivascular 
infiltration  with  lymphoid  and  plasma  cells.  There  is  some  neuroglia  prolifera- 
tion upon  its  surface,  and  the  new  tissue  is  infiltrated  with  lymphoid  cells. 
The  optic  nerve  is  apparently  normal.  Around  the  disc  the  retina  is  edema- 
tous,  showing  dilated  spaces  in  the  layer  of  Henle  filled  with  serum.  Some  of 
the  retinal  vessels  here  show  perivascular  infiltration  with  lymphoid  cells. 
The  ganglion-cells  are  reduced  in  number  anteriorly,  but  are  abundant  in  the 
macular  region.  The  choroid  is  normal. 

Sections  stained  by  Gram's  method  show  no  bacteria  within  the  globe.' 

CASE  2. — Spontaneous(?)  rupture  of  lens  capsule.  Marked  iridocyclitis. 
Enucleation.  Microscopic  examination  of  eye.  Dermal  and  intradermal  tests 
with  lens  protein  positive. 

Jessie  T.,  aged  fifty-eight,  came  to  the  Out-patient  Department  November 
24,  1920,  complaining  of  pain  in  the  right  eye.  Mother  was  living  and  blind 
with  cataracts,  and  one  aunt  lost  both  eyes  from  trouble  said  to  be  similar  to 
that  of  the  patient.  Twenty  years  ago  patient  had  iritis,  and  has  had  attacks 
off  and  on  ever  since,  but  never  severe.  No  history  of  trauma.  The  onset  of 
the  present  trouble  was  a  week  previous  to  present  date,  and  consisted  of 
pain  and  redness  of  the  right  eye.  On  examination  the  right  eye  revealed  a 
marked  conjunctival  and  ciliary  congestion;  the  cornea  was  clear,  iris  con- 
gested, and  pupil  blocked  by  a  membrane,  no  increase  in  tension;  light  pro- 
jection good;  convergent  squint.  The  left  eye  was  negative  as  regards  dis- 
ease. Vision  0.  S.  =20/20.  Patient  was  admitted  to  the  hospital.  January  5, 
1921,  no  permanent  improvement  having  taken  place  in  the  right  eye,  and  the 
globe  being  soft,  it  was  removed. 

On  October  10,  1921,  intradermal  and  dermal  tests  with  pig  lens  protein 
were  made  on  the  patient  and  were  markedly  positive. 

PATHOLOGIC  EXAMINATION 

(4187)  Fixation  in  10  per  cent,  formalin,  followed  by  acid  alcohol. 
The  epithelium  of  the  cornea. is  intact  at  the  periphery.  There  is  an  area 
4  mm.  in  diameter  in  the  center  which  is  denuded  of  epithelium.  Bowman's 
membrane  is  everywhere  intact,  but  markedly  altered  in  the  denuded  area. 
The  stroma  is  moderately  infiltrated  with  pus-cells  in  the  center  and  slightly 
so  in  the  periphery.  Vessels  are  invading  the  periphery,  extending  a  distance 
of  2  mm.  anterior  to  the  canal  of  Schlemm.  Descemet's  membrane  is  intact 


Endophthalmitis  Phacoanaphylactica  241 

but  swollen.  The  endothelium  is  intact.  There  is  a  peripheral  anterior 
synechia  on  one  side  which  extends  for  a  distance  of  3  mm.  Attached  to  the 
remainder  of  the  endothelium  are  numerous  cells,  consisting  chiefly  of  lym- 
phocytes and  plasma  cells,  with  a  few  large  mononuclear  and  pus-cells.  Rarely 
the  cells  are  agglutinated  into  clumps.  On  the  other  side  the  filtration  angle 
is  free,  but  the  ligamentum  pectinatum  is  sclerosed  and  infiltrated  with 
lymphocytes,  plasma  cells,  and  large  mononuclears.  The  tissues  of  the  limbus 
and  episcleral  tissue  extending  back  for  a  distance  of  3  mm.  are  infiltrated 
with  lymphoid  and  plasma  cells.  No  wound  of  the  cornea  is  found. 

The  iris  is  adherent  to  the  lens  by  a  large  posterior  synechia.  The  portion 
which  is  adherent  to  the  posterior  surface  of  the  cornea  retains  a  relatively 
normal  structure  for  a  distance  of  2  mm.  nearest  the  angle,  but  is  atrophic 
and  infiltrated  with  plasma  cells.  It  then  becomes  disorganized  and  incor- 
porated in  a  mass  of  dense  connective  tissue  which  forms  a  pupillary  mem- 
brane and  extends  into  the  lens.  Within  this  mass  the  sphincter  muscle  may 
be  seen  in  the  center  of  a  large  lymphocytic  nodule.  The  mass  is  markedly 
infiltrated  with  plasma  cells,  especially  around  the  lymphocytic  nodule,  and 
also  contains  numerous  pigmented  cells.  On  the  other  side  the  iris  is  atrophic 
and  markedly  infiltrated  with  plasma  cells,  and  near  the  pupil  it  shows  a  large, 
nodular  collection  of  lymphocytes.  The  dense  pupillary  membrane  continues 
over  the  posterior  surface  of  the  iris  to  the  ciliary  body,  fuses  the  iris  to  the 
lens,  and  on  one  side  extends  as  far  as  the  ora  serrata.  The  anterior  capsule 
is  swollen  to  two  or  three  times  its  normal  thickness  in  places,  while  in  others 
it  is  thinned.  At  about  the  center  it  shows  a  gap  2  mm.  wide  through  which 
the  connective  tissue  from  the  pupillary  membrane  invades  the  lens  sub- 
stance. The  lens  epithelium  is  proliferated  in  places  and  completely  destroyed 
in  others.  At  the  anterior  and  posterior  poles  the  lens  has  undergone  degenera- 
tion and  is  infiltrated  with  lime  salts,  but  is  here  practically  free  from  cells. 
The  dense  connective  tissue  invading  one  side  of  the  lens  has  walled  off  a 
portion  of  cataractous  lens  matter  at  the  equator.  The  other  side  of  the  lens 
is  also  invaded  by  connective  tissue  to  some  extent,  and  shows  deposits  of 
lime  salts.  In  the  central  portion  of  the  lens  is  a  somewhat  oval  mass  of 
lens  substance,  probably  the  nucleus,  measuring  3%  by  3V£  mm.  in  size. 
This  is  thickly  surrounded  by  endothelial  phagocytes  and  giant-cells,  a  few 
of  which  are  of  the  Langhans  type,  and  many  pus-cells.  The  latter  cells  have 
invaded  long  clefts  in  the  lens  substance  and  are  here  undergoing  necrosis. 
The  cyclitic  membrane  on  one  side  sends  a  thin  layer  of  fibrous  tissue  over  the 
posterior  surface  of  the  lens.  The  ciliary  body  shows  very  slight  cellular 
infiltration,  the  active  process  here  evidently  having  subsided. 

The  stellate  cells  of  the  vitreous  are  markedly  increased  in  number,  and  the 
anterior  vitreous  contains  also  numerous  round,  swollen  cells,  with  eccentric- 
ally placed  nuclei. 

The  optic  disc  shows  a  moderate  papilledema  and  proliferation  of  its  super- 
16 


242  F.  H.  VERHOEFF  AND  A.  N.  LEMOINE 

ficial  neuroglia.  The  optic  nerve  appears  normal.  The  retina  shows  central 
senile  retinitis,  with  marked  proliferative  and  degenerative  changes  of  the  pig- 
ment epithelium  associated  with  destruction  of  the  rods  and  cones  and  replace- 
ment of  the  outer  layers  of  the  retina  by  proliferated  neuroglia.  In  addition, 
the  retina  shows  several  large  cystic  spaces,  an  especially  large  one  filled  with 
serum  occupying  the  fovea.  The  retinal  ganglion-cells  are  present,  especially 
in  the  fundus. 

The  choroid  appears  normal. 

Sections  stained  by  Verhoeff's  modified  Gram's  stain  show  no  bacteria 
within  the  globe. 

CASE  3. — Spontaneous  rupture  of  capsule  of  cataractous  lens.  Marked 
iritis  with  descemetitis  and  hypopyon.  Enucleation.  Microscopic  examina- 
tion of  eye.  Dermal  and  intradermal  tests  with  lens  protein  positive. 

Julia  V.,  aged  seventy-two,  was  admitted  April  27, 1917,  complaining  of  pain 
in  the  left  eye,  which  had  its  onset  four  months  previously,  a  month  after  a 

successful  cataract  operation  by  Dr. on  the  other  eye.  It  began  with 

itching  and  burning  and  has  gradually  grown  worse.  No  history  of  bodily 
trauma  or  injury  to  eye. 

Examination  of  the  left  eye  at  this  time  revealed  moderate  congestion  of  the 
conjunctiva.  Cornea  dull,  with  deposits  on  the  posterior  surface.  Iris  con- 
gested. Pupil  small,  irregular,  and  did  not  react  to  light.  Exudate  in  pupil. 
No  fundus  reflex.  Light  projection  good.  Diagnosis:  Uveitis  0.  S.  The 
right  eye  presented  the  picture  of  a  successful  cataract  extraction.  Vision 
with  correction,  20/40.  A  complete  physical  examination  at  the  Massa- 
chusetts General  Hospital  was  negative.  Patient  given  1  per  cent,  atropin 
sulphate  and  hot  fomentations. 

May  1,  1917:  Tension  0.  D.  18  mm.;  0.  S.  38  mm.  Condition  about  the 
same. 

May  4,  1917:  Pupil  moderately  dilated.  Still  has  marked  descemetitis, 
otherwise  eye  quiet  and  pain  has  subsided. 

May  9,  1917:  Pupil  dilated  and  regular.  Descemetitis  still  present.  Exu- 
date in  pupil.  Tension  slightly  elevated.  Very  slight  congestion.  No  pain. 
Patient  discharged. 

July  3,  1917:  Patient  readmitted  to  wards.  Had  been  having  very  severe 
pain  in  0.  S.  for  a  month.  Examination  of  0.  D.  at  this  time  presented  same 
condition  as  on  discharge.  O.  S.  lids  slightly  swollen.  Conjunctiva  congested, 
especially  around  the  cornea.  Cornea  is  roughened  and  infiltrated.  Pupil 
contracted  and  filled  with  exudate.  Eye  very  tender  to  touch.  Anterior 
chamber  shallow.  Tension  ++.  Vision  nil. 

General  examination  at  Massachusetts  General  Hospital  negative,  except 
for  a  few  rales  at  base  of  lungs. 

Enucleation. 

October  19, 1921 :  Dermal  test  with  pig  lens  protein  positive.    Intradermal 


Endophihalmitis  Phacoanaphylactica  243 

test  with  pig  lens  protein  doubtful  after  one  and  one-half  hours,  markedly 
positive  after  twenty-four  hours. 

PATHOLOGIC  EXAMINATION 

(3325)  Fixation  in  10  per  cent,  formalin. 

The  tissues  of  the  limbus  and  episcleral  tissue  extending  back  for  a  distance 
of  1^2  mm.,  are  moderately  infiltrated  with  lymphocytes  and  a  few  plasma 
cells.  The  cornea  has  an  area  2  mm.  in  diameter  denuded  of  epithelium. 
Bowman's  membrane  is  intact  and  apparently  normal.  There  is  very  slight 
infiltration  of  the  stroma  with  leukocytes  and  beginning  vascularization, 
some  of  the  vessels  extending  1^  mm.  anterior  to  Schlemm's  canal.  Above 
there  is  a  peripheral  anterior  synechia  2  mm.  wide.  Below,  the  filtration 
angle  is  open.  Descemet's  membrane  is  intact.  The  endothelium  is  intact  in 
the  upper  portion,  but  destroyed  in  the  lower. 

The  lower  part  of  the  posterior  surface  of  the  cornea  is  coated  with  a  mem- 
brane partly  organized  and  rich  in  cells.  This  membrane  begins  as  a  thin 
layer  5  mm.  from  the  filtration  angle  above,  and  gradually  becomes  thicker 
below,  reaching  a  thickness  of  1  /16  mm.  It  contains  many  fibroblasts  evi- 
dently derived  from  the  corneal  endothelium,  numerous  pus-cells,  and  large 
and  small  mononuclear  cells.  The  pus-cells  are  abundant  next  to  Descemet's 
membrane.  The  posterior  surface  of  the  upper  part  of  the  cornea  is  practically 
free  from  cells  for  a  considerable  distance ;  then  clumps  of  mononuclear  cells 
appear,  which  increase  in  size  and  number  as  the  membrane  just  described  is 
approached. 

The  lower  filtration  angle  is  filled  with  a  hypopyon  2%  mm.  high,  com- 
posed of  serum,  fibrin,  and  cells.  The  cells  are  mostly  pus-cells,  plasma  cells, 
and  endothelial  leukocytes.  The  endothelial  leukocytes  are  intensely  phago- 
cytic,  being  engorged  with  chromatin  fragments.  The  hypopyon  also  con- 
tains a  moderate  amount  of  blood. 

The  iris  is  adherent  to  the  lens  by  a  large  posterior  synechia  on  both  sides. 
The  pupil  is  1^  mm.  wide,  and  filled  with  a  membrane  rich  in  cells,  many 
of  which  contain  pigment.  This  membrane  continues  between  the  iris  and 
lens  capsule  for  a  distance  of  2^  mm.  in  places.  The  anterior  surface  of 
the  iris  above  is  relatively  free  from  cells.  Below  it  is  coated  with  numer- 
ous cells,  consisting  chiefly  of  large  and  small  lymphocytes,  pus-cells,  and 
endothelial  phagocytes.  The  iris  stroma  is  markedly  infiltrated  with  plasma 
cells,  especially  posteriorly. 

The  lens  capsule  shows  a  defect  of  2J^  mm.  on  the  anterior  surface.  The  free 
ends  of  the  capsule  are  split,  and  the  clefts  invaded  by  endothelial  leukocytes 
and  a  few  pus-cells.  On  each  side  of  the  defect  the  lens  capsule  is  swollen. 
The  lens  epithelium  is  markedly  proliferated  at  the  edges  of  the  defect,  and  is 
apparently  giving  rise  to  a  few  phagocytic  cells.  Otherwise  the  epithelium 
appears  normal.  Along  the  inner  surface  of  the  pupillary  membrane  there  are 


244  F.  H.  VERHOEFF  AND  A.  N.  LEMOINE 

numerous  endothelial  leukocytes.  In  places  these  have  formed  syncytial 
masses  and  giant-cells.  Beneath  these,  directly  bordering  on  and  invading  the 
lens  substance,  there  is  a  layer  of  cells,  ^3  mm.  in  thickness.  These  cells  are 
almost  exclusively  pus-cells,  many  of  which  have  undergone  necrosis.  In 
places  the  pus-cells  have  extended  into  deep  clefts  within  the  lens  substance, 
and  here  are  completely  necrotic.  The  remainder  of  the  lens  cortex  is  cata- 
ractous,  but  the  nucleus  appears  normal. 

The  ciliary  body  is  very  slightly  affected,  being  only  sparsely  infiltrated 
with  plasma  cells  in  the  anterior  portion.  From  the  surface  of  the  pars  plana 
below  there  is  a  moderate  exudation  of  lymphocytes  and  plasma  cells. 

The  optic  nerve  and  disc  are  apparently  normal.  Some  of  the  vessels  in  the 
retina  show  slight  perivascular  infiltration  with  lymphocytes.  Otherwise  the 
retina  appears  normal.  The  choroid  is  apparently  normal. 

Sections  stained  by  Verhoeif  s  modified  Gram  stain  show  no  bacteria 
within  the  globe. 

CASE  4. — Perforating  wound  of  cornea,  iris,  and  lens.  Removal  of  for- 
eign body  by  magnet.  Iridocyclitis.  Enucleation.  Microscopic  examination 
of  eye.  Intradermal  test  with  lens  protein  positive. 

Henry  Q.,  aged  thirty-nine,  was  admitted  to  the  Massachusetts  Charitable 
Eye  and  Ear  Infirmary  May  21,  1919.  A  few  hours  before,  while  hammering 
a  pipe,  a  piece  of  steel  flew  and  struck  him  in  the  left  eye.  His  history  was 
otherwise  negative.  Examination  at  the  time  of  admission  was  negative  ex- 
c  pt  for  the  injury  to  the  left  eye.  The  eyelids  of  the  left  eye  were  slightly 
swollen  and  congested.  The  bulbar  conjunctiva  was  also  congested.  The 
cornea  showed  a  large  horizontal  perforating  wound  at  the  lower  edge  of  the 
pupillary  area.  The  iris  and  lens  showed  a  triangular  opening  on  the  tem- 
poral side  a  little  above  the  corneal  wound.  Pupil  reacted  to  light.  Fundus 
was  seen  with  difficulty.  Anterior  chamber  of  normal  depth.  Transillumina- 
tion  was  negative. 

X-r&y  examination  showed  a  foreign  body  localized  11  mm.  back,  4  mm. 
temporal  side,  4%  mm.  below,  size  1  x  ^  mm. 

May  22,  1919:  Dr.  Derby  removed  the  foreign  body  through  the  wound  in 
the  cornea  with  the  magnet. 

May  23:  Anterior  chamber  reformed.    Eye  very  red. 

May  26:  Eye  about  the  same ;  not  much  pain. 

May  31:  Marked  iritis.  Lens  swollen  and  cataractous.  Pupil  fairly  well 
dilated.  Pain  at  times. 

June  7:  Not  much  pain.    Eye  still  congested. 

June  18:  Slightly  better.    No  pain.    Not  so  much  congestion. 

June  26:  Eye  congested;  pain  at  times. 

July  1:  Enucleation. 

October  24,  1921 :  Intradermal  test  with  pigs  lens  protein  is  positive.  The 
dermal  test  is  doubtful. 


Endophthalmitis  Phacoanaphylactica  245 


PATHOLOGIC  EXAMINATION 

(3744)  Fixation  in  10  per  cent,  formalin. 

The  cornea  shows  a  large  horizontal  linear  healed  perforating  wound  just 
below  the  center.  The  corneal  epithelium  is  everywhere  intact,  but  shows  evi- 
dence of  bullous  keratitis  in  areas.  Bowman's  membrane  is  intact  except  at 
the  site  of  the  wound.  The  stroma  is  practically  free  from  cellular  infiltration. 
The  edges  of  the  wound  are  closely  approximated,  and  the  gap  filled  with  con- 
nective tissue  rich  in  cells.  The  contiguous  stroma  shows  very  little. evidence 
of  past  reaction.  At  the  periphery,  all  around,  there  are  a  few  new-formed 
blood-vessels  extending  for  a  distance  of  1^  mm.  anterior  to  the  canal  of 
Schlemm.  The  limbus  and  episcleral  tissues  extending  as  far  back  as  the 
equator  in  places  are  markedly  infiltrated  with  lymphoid  and  plasma  cells. 
Descement's  membrane  is  intact,  but  absent  over  short  stretches,  and  is  every- 
where coated  with  large  mononuclear  cells.  Often  these  are  agglutinated  into 
large  clumps.  Among  these  also  are  a  moderate  number  of  pus-cells  and  an 
occasional  eosinophile.  Attached  to  the  endothelium  are  a  number  of  small 
masses  of  altered  lens  matter  which  have  been  invaded  and  surrounded  by 
large  mononuclear  cells  and  a  few  cells  resembling  fibroblasts.  The  anterior 
chamber  is  filled  with  serum  containing  pus-cells,  lymphocytes,  and  occa- 
sionally an  eosinophile.  The  cells  become  more  numerous  as  the  lower  angle 
is  approached,  where  they  have  accumulated  in  the  form  of  a  hypopyon  1% 
mm.  high.  The  hypopyon  contains  also  a  considerable  amount  of  broken- 
down  lens  matter.  The  ligamentum  pectinatum  is  markedly  infiltrated  with 
similar  cells. 

Some  sections  show  beginning  adhesion  of  the  iris  root  to  the  ligamentum 
pectinatum.  The  iris  is  also  adherent  to  the  anterior  surface  of  the  lens 
capsule  by  a  wide  posterior  synechia.  The  anterior  surface  of  the  iris  is  cov- 
ered by  a  layer  of  leukocytes  consisting  of  lymphocytes,  large  mononuclears, 
and  pus-cells.  Some  of  the  large  mononuclears  are  agglutinated  into  clumps. 
The  lymphocytes  and  pus-cells  are  relatively  more  abundant. than  on  the 
posterior  surface  of  the  cornea.  The  stroma  of  the  iris  is  markedly  infiltrated 
with  lymphocytes  and  plasma  cells,  the  latter  predominating,  and  also  shows 
nodular  collections  of  lymphocytes. 

The  pupil  is  filled  with  a  dense  vascularized  fibrous  mass  rich  in  fixed  cells, 
forming  a  cone  which  is  continuous  with  the  tissue  filling  the  corneal  wound. 
This  mass  is  infiltrated  with  pus,  lymphoid  and  endothelial  cells,  some  of  the 
latter  containing  pigment.  The  center  of  this  cone  contains  a  mass  of  broken- 
down  lens  matter  invaded  and  surrounded  by  pus-cells  and  endothelial 
phagocytes. 

The  lens  capsule  shows  a  defect  of  1%  mm.  in  the  lower  half  of  the  anterior 
surface,  and  another  of  l/i  mm.  near  the  equator  on  the  posterior  surface  of  the 
same  side.  Where  the  capsule  is  intact,  it  is  adherent  to  the  iris  and  ciliary 


246  F.  H.  VERHOEFF  AND  A.  N.  LEMOINE 

processes.  The  anterior  capsular  epithelium  is  destroyed  in  places.  On  one 
side  the  pupillary  margin  of  the  iris  continues  into  a  thick  mass  of  connective 
tissue.  On  the  other  side  it  is  free  from  this  mass,  but  adherent  to  the  lens 
capsule.  Through  the  gap  in  the  lens  capsule  the  connective  tissue  has  ex- 
tended into  the  lens  substance  to  a  depth  of  2^  mm.,  and  spread  beneath  the 
capsule  on  one  side  for  a  distance  of  about  1  mm.  Beneath  the  connective 
tissue  the  lens  shows  marked  cataractous  changes,  is  breaking  up  into  hyaline 
balls,  and  shows  numerous  clefts.  It  is  being  invaded  by  numerous  endothelial 
phagocytes,  which  in  some  places  are  so  abundant  that  they  have  formed  a 
syncytium.  The  lens  substance  in  this  area  is  also  markedly  infiltrated  with 
pus-cells  many  of  which  have  undergone  necrosis.  The  posterior  cortex  shows 
cataractous  changes,  and  beneath  the  posterior  capsule  is  invaded  by  endothe- 
lial phagocytes  which  have  extended  from  the  gap  in  the  posterior  capsule. 
From  the  surface  of  the  ciliary  body  below  there  arises  a  thick  cyclitic  mem- 
brane, still  in  active  formation,  which  extends  up  to  and  through  the  gap  in 
the  posterior  capsule.  Within  this  membrane,  near  the  gap,  are  large  masses 
of  disintegrated  lens  material. 

The  ciliary  body  is  markedly  infiltrated  with  plasma  and  lymphoid  cells. 
Below  it  is,  in  addition,  highly  edematous.  The  surface,  above,  is  covered 
with  an  exudate  containing  endothelial  and  pus-cells,  about  which  a  cyclitic 
membrane  is  being  formed.  This  membrane  extends  as  far  back  as  the  ora 
serrata,  and  is  insignificant  in  comparison  with  that  over  the  lower  part  of  the 
ciliary  body  already  mentioned. 

The  vitreous  body  contains  a  small  disintegrating  foreign  body  about  1/10 
mm.  in  diameter,  evidently  left  behind  when  the  main  foreign  body  was  re- 
moved. This  is  inclosed  by  endothelial  cells  which  thus  form  a  small  foreign 
body  tubercle  free  in  the  vitreous. 

The  optic  disc  shows  moderated  papilledema  with  fairly  well-marked 
peri  vascular  infiltration  of  the  vessels.  In  the  center  beneath  the  surface  is 
an  area  infiltrated  with  lymphoid  and  plasma  cells.  There  is  also  some  pro- 
liferation of  the  surface  neuroglia  cells.  The  optic  nerve  appears  normal. 

The  retina  shows  marked  perivascular  infiltration  with  plasma  cells  and 
lymphocytes.  Attached  to  the  surface  of  the  retina  there  are  many  plasma 
cells,  lymphocytes,  and  large  mononuclear  cells.  Immediately  beneath  the 
internal  surface  there  are  numerous  small  foci  of  neuroglia  proliferation.  Some 
of  these  contain  a  slight  amount  of  iron  pigment  and  some  of  them  project  in 
nodular  form  into  the  vitreous.  The  ganglion-cells  are  everywhere  greatly 
diminished  in  number  except  in  the  macular  region,  where  they  are  still 
abundant. 

The  choroid  is  congested  but  free  from  infiltration  except  near  the  ora 
serrata,  where  it  shows  perivascular  infiltration. 

Sections  stained  by  Verhoeffs  modified  Gram  stain  show  no  bacteria 
within  the  globe. 


Endophthalmitis  Phacoanaphylactica  247 

CASE  5. — Extraction  of  mature  senile  cataract,  followed  by  iritis  and 
glaucoma.  Enucleation.  Microscopic  examination  of  eye.  Intradermal  tests 
with  lens  protein  positive. 

This  was  a  private  case  of  Dr.  Geo.  F.  Worcester's,  to  whom  we  are  indebted 
for  the  clinical  notes.  The  patient  was  seen  by  Dr.  Verhoeff  in  consultation 
December  9,  1921,  at  which  time  the  intradermal  tests  were  made. 

Mrs.  H.  A.  S.,  aged  seventy-three,  mature  cataract  0.  S.  immature,  O.  D. 

June  21,  1921:  Preliminary  iridectomy,  O.  S. 

July  30:  Cataract  extraction,  0.  S.    Some  soft  lens  matter  left. 

Anterior  chamber  found  reformed  at  first  dressing.  Reaction  slight.  No 
prolapse  of  iris. 

August  10:  Anterior  chamber  obliterated. 

August  27:  Iritis  with  descemetitis.  Edema  and  congestion  of  lids  (atropin 
irritation). 

September  15:  During  past  month,  anterior  chamber  has  reformed  and  pre- 
cipitates on  posterior  surface  of  cornea  have  diminished.  The  eye  is  now 
quiet. 

September  19:  0.  S.:  Anterior  chamber  obliterated.  Eye  very  much  con- 
gested. Tension  55  mm.  0.  D. :  Deep  anterior  chamber.  Pupil  dilated.  Slight 
ciliary  congestion.  (Subsequent  events  showed  this  was  an  attack  of  glau- 
coma, 0.  D.)  Enucleation  0.  S. 

September  24:  0.  D.:  Quiet.    V.  0.  D.  =  20/40. 

December  6:  0.  D.:  Congested,  cornea  hazy,  anterior  chamber  deep.  No 
posterior  synechia.  No  descemetitis.  Tension  25  mm.  V.  0.  D.  =  20/40. 
Atropin  ordered. 

December  8:  V.  0.  D.  =  20/100. 

December  9:  Patient  seen  by  Dr.  Verhoeff,  who  made  diagnosis  of  sub- 
acute  glaucoma  and  atropin  irritation  0.  D.  Eye  slightly  congested,  cornea 
steamy.  Pupil  widely  dilated.  No  posterior  synechia  or  descemetitis.  Ten- 
sion 36  mm.  (Souter).  V:  0.  D.  =  20/200.  Skin  of  both  eyelids  of  right  eye 
edematous  and  hyperemic.  Intradermal  tests  with  pig  lens  protein  made  in 
three  dilutions  by  Dr.  LeMoine. 

December  10:  Dr.  Worcester  reports  all  intradermal  tests  positive. 

PATHOLOGIC  EXAMINATION 

(4319)  Fixation  in  10  per  cent,  formalin. 

The  cornea  is  slightly  infiltrated  with  pus-cells  and  shows  a  few  vessels  ex- 
tending into  it  for  a  considerable  distance  from  the  periphery.  The  tissue  of 
the  limbus  is  densely  infiltrated  with  plasma  and  lymphoid  cells.  The  wound 
is  firmly  healed  everywhere  except  directly  above.  Here  the  anterior  lip  of  the 
wound  overrides  the  posterior,  and  the  two  lips  are  united  by  a  thick  mass  of 
granulation  tissue  which  is  densely  infiltrated  with  lymphoid  and  plasma  cells 
and  also  contains  numerous  eosinophiles.  On  each  side  the  site  of  the  wound  is 


248  F.  H.  VERHOEFF  AND  A.  N.  LEMOINE 

infiltrated  with  plasma  cells.  There  is  a  peripheral  anterior  synechia,  about 
2  mm.  wide  all  around,  but  the  iris  is  nowhere  incarcerated  in  the  wound. 
Attached  to  the  posterior  surface  of  the  cornea  there  is  a  thick  layer  composed 
of  large  and  small  lymphocytes  which  is  being  organized  by  the  corneal  en- 
dothelium.  There  are  also,  here  and  there,  adherent  to  the  posterior  surface, 
small  particles  of  lens  matter  containing  pus-cells. 

The  iris  is  densely  infiltrated  with  plasma  cells.  From  the  pupillary  margin 
there  arises  a  thick  pupillary  membrane  which  also  continues  behind  the  iris, 
fusing  the  latter  to  the  lens  capsule.  It  is  continuous  with  the  iris  stroma 
through  breaks  in  the  pigment  layer.  This  membrane  is  rich  in  epithelioid 
cells  and  contains  a  number  of  giant-cells.  Within  it  there  are  also  foci  of  pus- 
cells,  evidently  due  to  lens  matter  which  has  absorbed. 

Within  the  collapsed  lens  capsule  only  a  small  amount  of  lens  matter  re- 
mains. In  places  where  it  is  exposed  it  is  being  invaded  by  pus-cells. 

The  ciliary  body  is  free  from  infiltration,  and  from  its  surface  there  is  prac- 
tically no  cellular  exudation.  The  ciliary  processes  are  dragged  forward  and 
compressed.  The  choroid  is  normal.  The  retina  is  also  normal,  except  for 
slight  edema  of  the  macula  and  perivascular  infiltration  with  lymphoid  and 
plasma  cells  near  the  disc.  The  optic  disc  is  not  swollen  or  cupped,  but  shows 
considerable  perivascular  infiltration  with  lymphoid  and  plasma  cells.  The 
nerve  stem  shows  slight  infiltration  with  lymphoid  cells,  but  otherwise  appears 
normal. 

CASE  6. — Combined  extraction  of  immature  cataract,  with  early  discission 
followed  by  severe  iritis  and  attacks  of  increased  tension.  Dermal  tests  with 
lens  protein  positive. 

Fred  H.,  aged  fifty-five,  operated  upon  for  immature  cataract,  right  eye, 
by  Dr.  —  —  on  September  14,  1920.  Five  weeks  later,  discission  performed. 
Following  this  the  eye  was  greatly  irritated  and  there  were  attacks  of  increased 
tension.  Seen  by  Dr.  Verhoeff  in  consultation  on  November  17, 1920.  At  this 
time  the  right  eye  showed  moderate  congestion  but  considerable  photophobia. 
Apparently  only  a  small  amount  of  cortical  matter  remained  unabsorbed.  The 
pupil  was  contracted  and  drawn  up  and  the  iris  was  adherent  to  the  lens 
capsule.  There  was  one  large  white  precipitate  on  the  back  of  the  cornea. 
The  tension  was  2  mm.  (Souter).  In  view  of  the  history  of  attacks  of  in- 
creased tension,  2  per  cent,  solution  of  pilocarpin  nitrate  was  prescribed.  The 
left  eye  showed  an  immature  cataract. 

May  25,  1921 :  The  patient  was  again  seen  by  Dr.  Verhoeff.  Right  eye  was 
free  from  congestion.  Pupil  largely  obstructed  by  a  thick  capsule.  V.  0.  D. 
=  20/70. 

May  31 :  Discission  by  Dr.  Verhoeff.  Failing  to  get  a  good  opening,  the 
incision  was  enlarged  and  a  large  portion  of  the  capsule  pulled  out  by  forceps 
and  the  iris  sphincter  cut  below.  Considerable  hemorrhage  into  the  anterior 
chamber  resulted. 


Endophthalmitis  Phacoanaphylactica  249 

July  6:  A  considerable  amount  of  blood  remained  in  the  pupillary  area. 
V.  =  20  /200  with  glasses. 

July  7 :  Operation  by  Dr.  Verhoeff.  Iridectomy  and  capsulotomy.  Good 
opening  obtained. 

August  2:  Dermal  tests  with  pig  and  ox  lens  positive. 

August  6:  Dermal  test  with  human  immature  cataract  positive. 

September  27:  V.  with  +  9.50  S.  O  +  4.00  c.  ax.  170  =  20/40.  An  intra- 
capsular  extraction  was  performed  upon  the  left  eye  by  Dr.  Verhoeff.  This 
was  not  followed  by  iritis  or  glaucoma. 

CASE  7. — Combined  cataract  extraction  with  considerable  retention  of 
cortical  matter,  followed  by  severe  iritis,  descemetitis,  and  infiltration  of  the 
cornea.  Dermal  and  intradermal  tests  with  lens  protein  positive. 

Georgiana  M.,  aged  sixty-four,  came  to  the  Out-patient  Department  of  the 
Massachusetts  Charitable  Eye  and  Ear  Infirmary  March  3, 1921,  complaining 
of  progressively  failing  vision,  which  began  one  and  one-half  years  previously. 
Six  weeks  before  admission  she  had  a  slight  attack  of  inflammation  in  the  left 
eye,  possibly  iritis.  Otherwise  no  history  of  intraocular  inflammation  in 
either  eye  could  be  obtained. 

The  examination  revealed  nothing  of  importance  except  double  immature 
cataracts.  Both  pupils  reacted  to  light.  The  left  eye  showed  no  posterior 
synechia  or  pigment  on  the  lens,  but  the  right  eye  showed  one  small  posterior 
synechia.  Light  projection  good  0.  U.  On  March  5,  1921,  Dr.  Cheney  did  a 
combined  cataract  extraction  on  the  left  eye.  Considerable  cortical  matter 
was  left.  The  eye  was  quiet  and  apparently  the  cortical  matter  was  absorbing 
slowly  until  March  10,  when  the  eye  began  to  be  slightly  congested.  The 
inflammation  increased  so  that  by  March  17  the  patient  had  edema  of  the  lids, 
congestion  of  the  iris,  and  deposits  on  the  posterior  surface  of  the  cornea. 
Diagnosis:  iridocyclitis.  On  the  23d  the  patient  developed  hypopyon.  On 
the  31st  the  eye  was  soft  with  a  marked  hypopyon.  From  that  time  on  the 
patient  gradually  improved  and  was  discharged  from  the  hospital  April  18. 
At  this  time  the  eye  was  white  and  quiet.  The  pupil  was  drawn  up  and  filled 
with  a  dense  membrane.  The  upper  half  of  the  cornea  showed  mottled 
opacities.  Projection  was  good. 

The  patient  was  readmitted  to  the  wards  on  August  2,  1921.  At  that 
time  both  eyes  presented  very  much  the  same  condition  as  on  discharge 
except  that  posterior  synechiae  were  noted  in  the  right  eye.  Dermal  and  intra- 
dermal tests  with  pig  lens  protein  were  positive.  On  August  5  Dr.  Verhoeff 
did  a  combined  intracapsular  cataract  extraction  on  the  right  eye.  The 
patient  made  an  uneventful  recovery  and  was  ready  to  leave  the  hospital  on 
August  19.  At  this  time  a  discission  and  iridotomy  was  made  on  the  left  eye. 
Following  this  operation  the  patient  had  a  marked  reaction  in  the  eye. 

CASE  8. — Extraction  of  mature  senile  cataract  by  capsulotomy  method, 


250  F.  H.  VERHOEFF  AND  A.  N.  LEMOINE 

with  retention  of  cortical  matter  within  capsule.  Moderate  iritis.  Dermal 
tests  with  lens  protein  positive. 

Mary  M.,  aged  sixty-four,  was  admitted  to  the  Massachusetts  Charitable 
Eye  and  Ear  Infirmary  August  31, 1921,  complaining  of  progressively  failing 
vision  which  began  five  years  ago.  Examination  at  this  time  was  negative  ex- 
cept for  uncomplicated  mature  cataracts  0.  U.  Tension  was  normal.  Pro- 
jection good.  V.  O.  D.  =  20/200;  V.  0.  S.  =  20/200. 

September  1,  1921:  Dr.  Cheney  did  a  combined  cataract  extraction  O.  D. 
Some  cortical  matter  was  left. 

September  2 :  Dermal  tests  with  ox  and  pig  lens  protein  positive. 

September  3:  Eye  white.  Good  anterior  chamber.  Considerable  cortical 
matter.  Pupil  does  not  dilate  well.  Cornea  shows  striped  keratitis. 

September  6:  Slight  chemosis,  but  not  much  congestion.    No  pain. 

September  13:  Iritis  with  pain,  redness,  and  slight  chemosis. 

September  14 :  Dermal  tests  with  ox  and  pig  lens  protein  positive. 

September  16:  Chemosis  still  present,  but  iris  seems  clearer.    Less  pain. 

September  19:  Eye  much  whiter.  No  pain.  Cortical  matter  protected  by 
the  capsule. 

September  22:  Eye  much  whiter.  Patient  discharged.  V.  0.  D.  +  10.00 
=  5/200.  V.  O.  S.  =  2/200. 

CASE  9. — Old  injury  of  left  eye  with  iritis,  probably  due  to  lens  matter. 
Ten  years  later,  cataract  extraction  by  capsulotomy  method  right  eye,  fol- 
lowed by  iritis.  Later,  discission,  right  eye,  followed  by  iritis.  Intradermal 
test  with  lens  protein  positive. 

John  B.,  aged  seventy-three,  was  admitted  to  the  Massachusetts  Charitable 
Eye  and  Ear  Infirmary  June  20,  1920,  with  the  following  history:  Ten  years 
ago  had  an  injury  to  the  left  eye  which  caused  loss  of  vision  of  that  eye,  but 
never  had  much  pain  following  the  injury.  In  September,  1914,  patient  came 
to  the  Out-patient  Department  complaining  of  loss  of  vision  0.  U.  The  exam- 
ination at  that  time  revealed  0.  D.  Tension  34  mm.  V.  =  20  /40.  Field  of 
vision  contracted  about  10°.  Disc  not  cupped.  0.  S.  Tension  50  mm.  V.  = 
light  projection  faulty.  The  left  lens  was  cataractous,  the  pupil  dilated, 
irregular,  bound  down  to  the  lens  capsule,  and  the  iris  discolored.  There  was 
considerable  cortical  matter  left  in  the  capsule,  but  none  free.  In  June, 
1919,  vision  was  failing.  V.  O.  D.  =  counts  fingers  at  one  foot.  An  im- 
mature cataract  O.  D.  was  noticed.  Tension  normal  0.  U. 

At  the  time  of  admission  the  examination  revealed  the  following:  O.  D.: 
Nearly  mature  cataract,  light  projection  good.  Tension  +.  Congestion  of 
lids.  0.  S. :  No  change  since  first  examination.  Examination  at  the  Mas- 
sachusetts General  Hospital  was  negative. 

June  23,  1920:  Preliminary  iridectomy  0.  D. 

The  patient  made  an  uneventful  recovery  and  left  the  hospital  with  a  ten- 
sion of  20  mm.  0.  D. 


Endophthalmitis  Phacoanaphylactica  251 

October  10,  1920:  Cataract  extraction  0.  D.  by  capsulotomy  method  by 
Dr.  Lowell. 

October  21:  Anterior  chamber  reformed.  Complains  of  pain  0.  D.,  espe- 
cially at  night.  Eye  congested. 

November  5:  Iris  assuming  a  greenish  color  and  patient  has  much  pain. 
Eye  congested.  Pupillary  opening  drawn  far  up. 

November  29 :  Eye  beginning  to  quiet  down  and  pain  not  so  severe.  Exami- 
nation at  Massachusetts  General  Hospital  was  negative. 

December  8:  Continues  to  improve. 

December  29:  Good  anterior  chamber.  Iris  markings  distinct.  No  pain. 
Counts  fingers  at  one  foot. 

January  3,  1921:  Discharged.    Eye  practically  white  and  quiet. 

May  21:  Condition  about  the  same  as  upon  discharge. 

May  23:  Discission  0.  D. 

May  26:  Patient  has  much  pain.  Iris  much  inflamed.  Patient  referred  to 
Massachusetts  General  Hospital  for  a  general  examination  to  locate  cause  of 
iritis.  Examination  was  negative. 

June  26 :  Referred  to  the  Massachusetts  General  Hospital,  where  all  lower 
teeth  were  extracted. 

July  15:  Eye  whitening.    Pupil  contracted. 

July  18:  Discharged. 

October  25:  Intradermal  test  with  pig  lens  protein  positive. 

CASE  10. — Senile  immature  cataract.  Intracapsular  extraction  with 
rupture  of  capsule  and  retention  of  some  lens  matter  in  anterior  chamber, 
followed  by  iritis.  Intradermal  test  with-lens  protein  positive. 

Mr.  S.,  aged  sixty-four,  was  admitted  November  1,  1921,  with  bilateral 
immature  senile  cataracts.  V.  O.  D.  =  shadows.  0.  S.  =  20/50.  No  his- 
tory of  any  inflammatory  condition  of  either  eye. 

November  2, 1921 :  Combined  intracapsular  extraction  with  capsule  forceps 
right  eye,  by  Dr.  Verhoeff.  Rupture  of  the  capsule  occurred  just  as  the 
cataract  was  being  delivered.  A  moderate  amount  of  cortical  matter  escaped 
into  the  anterior  chamber  and  was  allowed  to  remain  there.  The  entire 
capsule,  however,  came  away. 

November  4:  Anterior  chamber  reformed.  Cortical  matter  about  4  mm. 
in  diameter,  adherent  to  cornea,  not  in  contact  with  iris. 

November  8:  Intradermal  test  with  pig  lens  protein  positive. 

November  12:  There  has  been  a  moderate  amount  of  pain,  especially  at 
night.  The  eye  is  markedly  congested.  The  pupil  is  only  half  dilated  under 
atropin.  The  cortical  matter  is  half  absorbed;  a  small  amount  of  it  lies  in 
the  lower  angle  in  contact  with  the  iris. 

November  14:  Pupil  more  contracted.  Eye  markedly  congested.  Mod- 
erate amount  of  pain.  The  iris  below,  where  the  cortical  matter  lies  upon  it, 
is  congested  and  coated  with  a  slight  amount  of  exudate. 


252  F.  H.  VERHOEFF  AND  A.  N.  LEMOINE 

November  18:  Pain  and  congestion  more  marked.  Two  pieces  of  cortical 
matter  are  adherent  to  the  anterior  surface  of  the  iris,  one  below  and  one  in 
the  lower  nasal  quadrant.  Iris  much  swollen  in  the  vicinity  of  each  piece  of 
cortical  matter  and  coated  with  a  slight  amount  of  exudate.  Eyelids  con- 
gested and  somewhat  swollen — atropin  irritation  ?  Hyoscin  substituted  for 
atropin. 

November  23:  Lens  matter  all  absorbed  except  for  a  small  piece  adherent  to 
the  hyaloid  membrane  and  not  in  contact  with  the  iris.  Congestion  much 
less,  no  pain.  V.  0.  D.  with  correction  =  20/40. 

DecemberS:  0.  D.  still  moderately  congested.  The  iris  shows  a  number  of 
posterior  synechiae.  A  small  bit  of  lens  matter  remains  adherent  to  the 
hyaloid  membrane. 

December  22:  0.  D.  practically  free  from  congestion.  The  former  site  of 
the  lens  matter  on  the  hyaloid  membrane  appears  as  a  slightly  pigmented 
spot.  V.  0.  D.  with  sph.  +  12.5  o  +  1  cyl.  ax.  155°  =  20/30. 

CASE  11. — Immature  cataract.  Attempted  intracapsular  extraction.  Rup- 
ture of  capsule  and  retention  of  cortical  matter.  Chronic  iridocyclitis  and 
complete  occlusion  of  pupil.  Intradermal  test  with  lens  protein  positive. 

Charles  S.,  aged  sixty-six,  was  admitted  to  the  wards  of  the  Massachusetts 
Charitable  Eye  and  Ear  Infirmary  May  19, 1921,  complaining  of  failing  vision 
in  both  eyes  of  ten  years'  duration.  His  history  was  otherwise  negative, 
except  that  he  had  been  subject  to  attacks  of  asthma,  which  usually  came  on 
in  the  fall  of  the  year,  when  hay-fever  was  most  prevalent.  He  had  never  had 
any  pain  or  inflammation  in  his  eyes.  The  examination  was  negative  at  this 
time,  except  for  double  immature  nuclear  cataracts.  V.  0.  U.  =  counts  fingers 
at  two  feet. 

May  20:  Right  eye.  Intracapsular  extraction  attempted,  but  capsule 
ruptured.  The  lens  was  then  extracted  by  the  ordinary  method. 

May  23:  Incision  healed.    Very  little  reaction. 

May  27 :  Eye  whitening.    Good  anterior  chamber.    Bandage  off. 

May  30 :  Eye  looks  whiter  each  day. 

June  4:  Patient  discharged.  V.  with  sph.  +  10  o  +  1  cyl.  axis  15°  = 
20/30. 

June  23:  Eye  white.    Small  piece  of  floating  cortical. 

July  14:  V.  0.  D.  sph.  +  10  =  20/70,  Thin  membrane.  Some  vitreous 
opacities.  Chronic  cyclitis  (?). 

October  6:  Patient  states  that  for  the  past  seven  weeks  he  has  had  severe 
inflammation  of  right  eye  with  slight  pain.  Treated  by  local  doctor.  Pupil 
closed  and  drawn  up.  Tension  subnormal.  Light  projection  very  poor. 
Slight  pericorneal  congestion. 

December  2:  Eye  quiet.    Intradermal  test  with  pig  lens  protein  positive. 

CASE  12. — Perforating   wound   of   cornea.     Traumatic   cataract  partly 


Endophthalmitis  Phacoanaphylactica  253 

removed  by  linear  extraction.  Iridocyclitis.  Lens  matter  removed  by  irriga- 
tion. Rapid  recovery.  Intradermal  tests  with  lens  protein  positive. 

Louis  S.,  aged  thirty-eight,  admitted  to  the  hospital  March  18,  1921.  Eight 
weeks  before  was  struck  in  the  right  eye  by  a  carpet  tack.  Ten  days  later  was 
operated  upon  for  cataract.  The  eye  became  progressively  more  and  more 
congested  but  not  painful,  and  the  patient  was  advised  by  two  ophthalmolo- 
gists to  have  it  removed  owing  to  danger  of  sympathetic  ophthalmia. 

Examination:  Moderate  pericorneal  congestion.  The  cornea  shows  a  small 
healed  perforating  wound  near  the  center  and  a  healed  linear  cataract  incision 
above.  No  anterior  synechia  or  evidence  of  injury  to  the  iris.  On  the  posterior 
surface  of  the  cornea  there  are  numerous  large  white  precipitates,  and  there 
is  a  small  hypopyon  (lens  matter?).  The  pupil  is  contracted  and  partly  ob- 
structed by  opaque  capsule.  No  tenderness  on  pressure.  Tension  21  mm. 
(Souter).  Vision  =  counts  fingers  at  one  foot.  Left  eye  normal. 

Owing  to  the  absence  of  any  involvement  of  the  left  eye  in  spite  of  the 
marked  descemetitis  in  the  right,  and  to  the  lack  of  any  injury  to  the  uveal 
tract,  sympathogenic  uveitis  was  excluded  by  Dr.  Verhoeff,  and  a  diagnosis 
made  of  iridocyclitis  due  to  lens  matter. 

March  19, 1921 :  Operation  by  Dr.  Verhoeff.  A  small  keratome  incision  was 
made  above,  and  a  large  amount  of  lens  matter,  together  with  the  hypopyon 
and  precipitates  on  the  cornea,  removed  by  irrigation.  A  large  piece  of  the 
anterior  capsule  was  removed  by  forceps.  Two  hours  later  the  anterior 
chamber  was  reformed,  the  cornea  was  free  from  precipitates,  and  the  pupil 
was  clear. 

March  22:  Some  fibrin  in  pupillary  area.    No  descemetitis. 

March  25:  Fibrin  absorbed.    Eye  healing  well. 

April  7:  The  eye  shows  evidence  of  atropin  irritation.  Hyoscin  in  y$  per 
cent,  solution  substituted  for  atropin. 

The  eye  then  made  an  uneventful  recovery,  and  on  May  2  had  vision  of 
20  /40  with  cataract  glass.  On  July  2  a  discission  of  the  lens  capsule  was  per- 
formed without  reaction  following,  and  on  July  13  vision  of  20/30  was  ob- 
tained in  spite  of  the  corneal  scar. 

December  7,  1921:  Intradermal  test  with  pig  lens  protein  positive. 

Attempting  to  ascertain  the  percentage  of  individuals  in  general 
who  are  hypersensitive  to  lens  protein,  we  have  made  dermal  or  in- 
tradermal  tests  in  50  cases  of  various  eye  conditions.  These  cases 
were  unselected  so  far  as  concerned  the  existence  or  non-existence 
of  inflammatory  reaction  dependent  upon  injury  to  the  lens. 

The  ages  were:  Under  twenty  years,  9  cases;  twenty  to  forty 
years,  9  cases;  forty  to  sixty  years,  8  cases;  over  sixty  years,  24  cases. 
There  were  26  males  and  24  females.  There  were  30  cases  in  which 


254  F.  H.  VERHOEFF  AND  A.  N.  LEMOINE 

there  was  perforation  or  rupture  of  the  lens  capsule.  Four  were 
cases  of  perforating  injury  of  cornea  and  lens  with  retained  foreign 
body  which  was  removed  through  the  anterior  chamber,  and  26  were 
cataract  cases.  Of  the  cataract  cases,  four  were  cases  of  congenital 
cataract,  in  which  the  eyes  were  operated  upon  by  discissions;  22 
were  cases  of  senile  cataract.  In  5  of  the  latter  cases  cataract  ex- 
traction by  the  capsulotomy  method  had  previously  been  per- 
formed, recently  followed  by  discissions,  while  in  13,  extraction  by 
the  capsulotomy  method  was  subsequent  to  the  tests.  In  the  re- 
maining cataract  cases  the  tests  were  made  a  few  days  after  the 
cataract  extractions. 

The  tests  were  definitely  positive  in  only  4  of  the  50  cases:  one 
was  a  case  of  interstitial  keratitis  in  a  female  aged  thirteen  years; 
one  a  case  of  mature  senile  cataract  in  a  female  aged  sixty-four,  and 
two  were  cases  of  immature  cataract  operated  upon  by  the  intra- 
capsular  method,  in  which  the  ages  were  forty-six  and  sixty-four 
years.  Intraocular  inflammation  occurred  in  the  two  cataract  cases, 
Cases  8  and  10,  described  above,  in  which  lens  matter  was  left  in  the 
eye  at  operation,  and  not  in  the  other  cataract  case  in  which  the  lens 
was  removed  with  its  capsule  intact. 

The  important  question  whether  patients  who  fail  to  show  intra- 
ocular reaction  following  injury  to  the  lens  are  insensitive  to  lens 
protein  is  answered  in  the  affirmative  by  the  foregoing  series  of  cases, 
since  in  the  30  cases  of  perforation  or  rupture  of  the  lens  capsule  in- 
flammatory reaction  occurred  only  in  the  two  cases  in  which  there 
was  a  positive  skin  reaction  to  lens  protein. 

To  determine  whether  or  not  the  histologic  changes  following 
rupture  of  the  lens  capsule  in  sensitized  individuals  are  such  as  to 
indicate  that  they  are  due  solely  to  lens  matter,  we  have  studied 
these  changes  in  the  five  positive  cases  described  above,  in  which 
pathologic  examinations  were  made,  and  compared  them  with  the 
changes  found  in  sections  of  all  eyes  in  the  pathologic  collection  of 
this  laboratory  which  showed  injury  to  the  lens.  We  find  that  the 
injured  lens  in  individuals  hypersensitive  to  lens  protein  attracts 
chiefly  two  types  of  cells,  namely,  pus-cells  and  endothelial  phago- 
cytes. The  pus-cells  infiltrated  the  lens  substance,  and  when  lens 
matter  is  present  in  the  anterior  chamber,  collect  here  also.  These 
cells  after  a  time  undergo  necrosis,  especially  when  present  in  abun- 
dance. Eosinophiles  are  generally  inconspicuous  but  are  sometimes 
abundant.  The  endothelial  phagocytes  likewise  invade  the  lens 


Endophthalmitis  Phacoanaphylactica  255 

substance  and  may  be  seen  in  the  act  of  phagocyting  it.  Sometimes 
they  form  thick  syncytical  masses  bordering  upon  the  lens  substance, 
and  often  form  giant  cells  of  the  Langhans  type.  Endothelial 
phagocytes  are  also  sometimes  abundant  in  the  anterior  chamber, 
and  here  are  often  loaded  with  pus-cells  and  chromatin  fragments. 

The  iris  is  infiltrated  with  lymphocytes  and  plasma  cells,  the  latter 
greatly  predominating,  while  attached  to  its  surface  there  are  large 
and  small  lymphocytes  and  pus-cells.  Similar  cells  also  are  col- 
lected upon  the  posterior  surface  of  the  cornea  where  they  tend  to 
occur  in  clumps.  The  collection  of  cells  on  the  back  of  the  cornea 
may  be  so  massive  that  it  causes  proliferation  of  the  endothelium  and 
extensive  formation  of  fibrous  tissue  here  (Case  3).  Where  the 
process  is  especially  active,  there  may  be  a  moderate  amount  of 
fibrin  and  blood  in  the  anterior  chamber  (Case  3). 

From  the  pupillary  margin  of  the  iris,  fibroblasts  and  blood  capil- 
laries extend  over  and  invade  the  injured  lens  and  close  it  off  so  that 
ultimately  further  egress  of  lens  material  to  the  anterior  chamber  is 
cut  off  by  fibrous  membrane.  There  is  more  or  less  proliferation 
also  of  the  capsular  epithelium,  which  after  a  time  leads  to  the  forma- 
tion of  anterior  capsular  cataract.  The  capsular  epithelium  in  addi- 
tion seems  to  give  rise  to  a  few  free  ameboid  cells  which  phagocyte 
the  lens  material,  but  these  cells  are  so  similar  to  the  endothelial 
phagocytes  that  it  is  difficult  to  distinguish  them  from  the  latter. 

In  the  cases  in  which  adhesion  of  the  iris  to  the  lens  prevented  lens 
material  from  reaching  the  vitreous  chamber  the  posterior  part  of 
the  eye  shows  little  reaction.  When  there  is  access  of  lens  matter 
to  the  vitreous,  the  ciliary  body  shows  more  or  less  reaction.  The 
interstitial  infiltration,  however,  is  relatively  slight,  and  the  infiltrat- 
ing cells  consist  almost  exclusively  of  plasma  cells.  From  the 
epithelial  surface  there  is  an  exudation  of  plasma  cells  and  lympho- 
cytes. The  ciliary  epithelium  shows  proliferative  changes  and  may 
give  off  many  free  epithelial  cells  into  the  vitreous;  in  Cases  2  and  4 
dense  cy clitic  membranes  have  been  formed.  The  choroid  shows  no 
involvement  except  anteriorly  where  the  infiltration  of  the  ciliary 
body  may  continue  into  it  for  a  short  distance.  The  retina  shows 
perivascular  infiltration  with  lymphocytes  and  more  or  less  edema 
around  the  disc  and  in  the  macular  region.  In  Case  4  there  are 
nodular  collections  of  lymphocytes,  plasma  cells,  and  large  mono- 
nuclear  cells  on  the  inner  surface  of  the  retina  and,  in  places,  localized 
foci  of  neuroglia  proliferation  beneath  the  surface.  The  optic  disc 


256  F.  H.  VERHOEFF  AND  A.  N.  LEMOINE 

shows  perivascular  infiltration  with  lymphoid  cells,  slight  edema, 
and  in  Cases  1,  2,  and  4,  neuroglia  proliferation  along  its  surface. 

In  the  pathologic  collection  of  the  Infirmary,  covering  a  period  of 
twenty-one  years,  we  are  able  to  find  sections  from  25  cases  of  injury 
to  the  lens  in  addition  to  those  already  described,  which  show  changes 
which  we  regard  as  characteristic  of  phacoanaphylactic  endophthal- 
mitis.  We  also  find  sections  from  ten  cases  in  which  we  are  unable 
to  determine  whether  or  not  the  inflammatory  reaction  was  due  to 
anaphylaxis.  In  each  of  these  cases  the  lens  was  infiltrated  solely 
with  endothelial  phagocytes,  and  in  one  there  was  a  tubercle  on  the 
anterior  surface  of  the  iris  due  to  lens  matter  which  had  been  sur- 
rounded by  endothelial  leukocytes  and  giant  cells.  Whether  or  not 
in  these  cases  the  inflammation  was  anaphylactic  in  nature  it  is  diffi- 
cult to  say,  but  the  clinical  fact  that  injury  to  the  lens  is  often  fol- 
lowed by  no  inflammatory  reaction  suggests  that  in  some  of  these 
cases  the  reaction  may  have  been  the  result  of  low-grade  sensitiveness 
to  lens  protein.  As  a  matter  of  fact,  three  of  the  patients  returned 
later  and  each  gave  a  doubtful  intradermal  reaction  with  lens  protein. 
Moreover,  in  the  same  pathologic  collection  we  are  able  to  find  sec- 
tions from  five  cases  in  which  injury  to  the  lens  had  caused  no  reaction. 
That  so  few  specimens  of  this  kind  can  be  found  is  obviously  explained 
by  the  fact  that  only  under  exceptional  circumstances  are  such  eyes 
removed. 

ANIMAL  EXPERIMENTS 

In  these  experiments  our  purpose  was  to  ascertain  the  effects  pro- 
duced by  discissions  of  the  lens  capsule  in  normal  animals  and  in  ani- 
mals sensitized  to  lens  protein.  Guinea-pigs  and  rabbits  were 
employed.  Ether  narcosis  was  employed  in  all  experiments  except 
three,  in  which  cocain  was  instilled  before  operation.  All  enucleated 
eyes  were  fixed  in  Zenker's  fluid  and  embedded  in  celloidin.  Sections 
were  stained  in  hematoxylin  and  eosin,  and  by  Verhoeff  s  modified 
Gram  stain  for  bacteria.  No  bacteria  were  found  except  in  the  right 
eye  of  Exp.  1 ,  which  was  infected  with  streptococci.  In  connection  with 
the  Gram  stain  it  may  be  well  to  state  here  that  the  cataractous  lens 
after  fixation  often  in  places  appears  to  have  undergone  transforma- 
tion into  fine  granules,  some  of  which  are  basophilic  and  stain  deeply 
by  the  Gram  method.  Such  granules  sometimes  occur  in  pus-cells, 
possibly  due  to  precipitation  of  lens  material  within  the  latter,  and 
often  closely  resemble  large  cocci. 

In  our  preliminary  experiments  %  gm.  of  pig  lens  was  injected 


Endophthalmitis  Phacoanaphylactica  257 

subcutaneously  into  •  each  of  four  guinea-pigs.  All  of  them  died 
within  three  weeks,  showing  that  too  large  a  dose  had  been  used. 
We  then  reduced  the  dose  to  1/24  gm.  per  100  gm.  of  body  weight 
and  had  no  further  lethal  effects.  Intradermal  skin  tests  were 
made  at  the  end  of  four  weeks  to  ascertain  whether  or  not  the  animals 
were  hypersensitive,  and  all  of  the  injected  animals  gave  positive 
tests.  One  of  the  control  guinea-pigs  (Exp.  6)  tested  in  the  same 
way  gave  a  negative  reaction.  Seventeen  days  later  a  discission  was 
performed  upon  his  right  lens.  This  gave  rise  to  so  much  reaction 
that  we  suspected  that  he  had  been  sensitized  by  the  subcutaneous 
test  previously  made.  On  making  another  intradermal  test  we  found 
that  this  was  actually  the  case,  so  that  we  desisted  from  making  these 
tests  in  our  control  experiments.  Following  are  the  protocols  of  the 
experiments : 

EXPERIMENT  1  (Fig.  3). — August  1,  1921:  Guinea-pig  weighing  515  grams. 
5  /24  gram  of  pig  lens  protein  injected  subcutaneously. 

August  27 :  Intradermal  tests  with  pig  and  ox  lens  markedly  positive. 

August  30:  O.  D.    Discission. 

September  1:  Lens  cloudy.  Slight  injection,  no  marked  reaction.  Dis- 
cission opening  closing. 

September  13:  0.  D.    Discission  opening  completely  closed.    Eye  quiet. 

September  14:  -0.  D.  Second  discission.  Following  this  operation  the  eye 
became  infected  with  streptococci  so  that  further  notes  upon  it  are  omitted. 

September  21 :  Discission  0.  S. 

September  23:  Lens  cloudy.  Slight  pericorneal  congestion.  Enucleation 
O.  S. 

Microscopic  Examination. — 0.  S. :  The  cornea  is  edematous  and  consider- 
ably infiltrated  with  pus-cells.  There  are  also  a  few  pus-cells  attached  to  the 
endothelium.  The  filtration  angle  is  free,  but  contains  many  pus-cells  and 
endothelial  phagocytes  filled  with  pus-cells.  These  cells  are  also  abundant 
in  the  meshwork  of  the  ciliary  body.  The  iris  is  practically  normal,  but  shows 
a  large  posterior  synechia  on  one  side.  The  lens  capsule  is  intact  and  appears 
normal  except  for  a  gap  of  %  mm.  wide  in  the  center.  Through  this  gap  the 
lens  matter  has  projected  and  formed  a  nodule  about  1  mm.  in  diameter.  In 
the  center  of  the  nodule  the  lens  matter  is  comparatively  normal,  but  becomes 
more  and  more  cataractous  toward  the  surface,  being  here  broken  up  into 
balls  and  liquefied.  The  surface  of  the  nodule  is  covered  with  a  delicate  but 
thick  layer  of  fibrin  which  completely  fills  the  pupillary  area.  The  lens  matter 
has  become  invaded  with  pus-cells  which  form  a  definite  boundary  to  the 
nodule.  Numerous  pus-cells  have  also  invaded  deeply  into  the  nodule,  many 
of  them  being  seen  even  in  the  center.  At  the  periphery  are  also  a  number  of 
17 


258 


F.  H.  VERHOEFF  AND  A.  N.  LEMOINE 


ce'ls  evidently  derived  from  the  lens  epithelium.  Pus-cells  also  extend  through 
the  gap  in  the  capsule  for  a  distance  of  ]A,  mm.  into  the  main  body  of  the  lens. 
The  latter  shows  cataractous  changes  at  the  periphery,  extending  backward 
almost  as  far  as  the  posterior  pole.  The  capsular  epithelium  shows  marked 


Fig.  3,  Exp.  1. — Showing  lens  changes  forty-eight  hours  after  discission  of  left 
lens  of  sensitized  guinea-pig.  The  lens  substance  has  protruded  through  the  gap 
in  the  capsule  in  the  form  of  a  nodule.  The  latter  is  coated  with  fibrin  and  pus- 
cells,  and  is  deeply  invaded  by  pus-cells,  some  of  which  have  also  extended  through 
the  gap  in  the  capsule  into  the  main  lens  substance.  (Photo  X  75.) 

proliferation,  many  of  the  cells  being  in  mitosis,  and  in  places  has  already 
trebled  in  thickness. 

EXPERIMENT  2  (Fig.  4). — August  1,  1921.  Guinea-pig  weighing  470  grams. 
5  /24  gram  of  pig  lens  protein  injected  subcutaneously. 

August  27:  Intradermal  tests  with  ox  and  pig  lens  protein  both  markedly 
positive. 

August  30:  Discission  0.  D. 


Endophthalmitis  Phacoanaphylactica 


259 


August  31 :  Lens  cloudy.    No  reaction. 

September  5:  Eye  quiet.    Discission  opening  practically  closed. 
September  14:  Discission  opening  closed.    Second  discission  0.  D. 
September  17:  No  reaction.    Discission  opening  practically  closed.    Lens 
slightly  cloudy.    Third  discission  0.  D. 


Fig.  4,  Exp.  2. — Showing  deeply  seated  purulent  infiltrate  in  lens  twenty- 
seven  days  after  discission  of  right  lens  of  sensitized  guinea-pig.  The  pus-cells 
are  mostly  necrotic.  (Photo  X  400.) 


September  20:  Edema  of  the  lids.  Circumcorneal  congestion.  Iris  con- 
gested. Lens  cloudy. 

September  22:  Pericorneal  congestion  marked.  Vessels  have  invaded  the 
cornea  from  above  for  a  distance  of  2  mm.  Iris  congested,  markings  are  indis- 
tinct. Vessels  are  invading  the  anterior  surface  of  the  cloudy  lens. 

September  24:  Cornea  becoming  vascular  all  around.  Pericorneal  con- 
gestion not  so  marked.  Iris  and  lens  about  the  same. 


260  F.  H.  VERHOEFF  AND  A.  N.  LEMOINE 

September  26:  Eye  whiter.  Corneal  vessels  disappearing,  also  vessels  of 
lens  are  not  so  marked.  Discission  opening  practically  closed.  Iris  not  so 
congested.  Discission  0.  S.  Enucleation  O.  D. 

October  1 :  0.  S. :  Discission  opening  closed.  Lens  slightly  cloudy.  No 
reaction. 

October  5:  Second  discission  0.  S. 

October  11:  Intradermal  test  with  pig  lens  protein  negative.  O.  S.:  Lens 
nearly  clear.  No  reaction. 

Microscopic  Examination. — 0.  D. :  The  cornea  is  edematous  and  thickened 
to  twice  its  normal  thickness.  The  corneal  corpuscles  are  increased  in  num- 
ber throughout  and  the  stroma  is  moderately  infiltrated,  chiefly  with  pus- 
cells.  This  infiltration  increases  as  the  sclerocorneal  margin  is  approached. 
Vessels  have  invaded  the  whole  cornea  except  a  small  area  3  mm.  in  diameter 
in  the  center.  The  endothelium  is  intact  except  for  a  few  small  areas  near  the 
wounds  of  the  discissions.  Attached  to  the  lower  two-thirds  of  the  endothe- 
lium are  numerous  pus-cells  and  endothelial  phagocytes;  many  of  the  latter 
are  in  clumps  and  engorged  with  pigment  and  chromatin  fragments.  The 
anterior  chamber  is  filled  with  serum.  The  filtration  angle  is  open.  The 
meshwork  at  the  angle  is  infiltrated  with  pus-cells  and  endothelial  phagocytes 
many  of  which  are  engorged  with  chromatin  fragments  and  pus-cells.  The  iris 
is  adherent  near  the  periphery  to  one  of  the  discission  wounds  in  the  cornea, 
and  is  adherent  on  one  side  to  the  lens  by  a  large  posterior  synechia.  It  is 
markedly  congested  and  is  slightly  infiltrated  with  pus-cells  and  a  few  plasma 
cells.  There  is  a  pupillary  membrane  which  is  continuous  with  the  pupillary 
margin  of  the  iris  all  around  and  extends  over  and  into  the  anterior  boundary 
layer.  In  the  center  it  forms  a  conical  mass  which  is  connected  with  one  of 
the  discission  wounds  anteriorly.  Three  openings  can  be  found  in  the  lens 
corresponding  to  the  three  discissions.  Through  these  openings  connective 
tissue  extends  between  the  capsule  and  the  lens  substance  on  one  side  as  far 
back  as  the  equator.  Immediately  beneath  this  connective  tissue  the  lens 
substance  shows  a  large  area  of  liquefaction  within  which  there  are  large  num- 
bers of  endothelial  phagocytes  and  pus-cells.  Many  of  the  latter  are  necrotic. 
Behind  this  area  the  lens  substance  shows  deep  clefts  containing  liquefied  lens 
matter,  hyaline  balls,  and  many  pus-cells  which  are  here  especially  necrotic. 
Pus-cells  can  also  be  found  in  small  numbers  within  the  solid  lens  substance 
throughout  its  entire  thickness.  Even  when  occurring  singly  these  cells  lie  in 
small  vacuoles  evidently  due  to  liquefaction  of  the  lens  substance  around 
them.  The  anterior  capsule  is  about  one  and  three-quarters  its  normal  thick- 
ness. Near  the  discission  openings  the  capsular  epithelium  is  not  recognizable, 
but  a  short  distance  from  them  it  appears  always  at  least  two  cells  in  thickness, 
and  sometimes  in  the  form  of  a  capsular  cataract.  At  the  equator  on  one  side, 
where  the  capsule  is  greatly  wrinkled,  the  capsular  epithelium  is  proliferated 
into  a  thick  mass  in  which  numerous  balls  of  lens  matter  have  been  incor- 


Endophihalmitis  Phacoanaphylactica  261 

porated.  Near  the  posterior  pole  the  capsule  shows  a  gap  1  mm.  wide.  Here 
the  lens  matter  is  cataractous  and  markedly  infiltrated  with  endothelial 
phagocytes  and  pus-cells. 

The  vitreous  is  infiltrated  with  serum,  which  is  more  concentrated  pos- 
teriorly. In  the  vitreous,  approaching  the  gap  in  the  posterior  capsule,  there 
are  many  pus-cells  and  a  few  lymphocytes. 

The  ciliary  body  is  infiltrated  with  plasma  cells  and  lymphocytes  through- 
out, and  in  places  shows  nodular  collections  of  these  cells. 

The  surface  epithelium  shows  proliferative  changes  and  is  giving  off  num- 
bers of  round  cells. 

The  optic  disc  is  congested  and  greatly  swollen,  and  is  giving  off  small  and 
large  lymphocytes  into  the  vitreous. 

The  choroid  and  retina  are  normal,  with  the  exception  that  the  retina 
apparently  shows  edema  of  the  ganglion-cell  layer. 

EXPERIMENTS. — August  4,  1921.  Guinea-pig  weighing  355  grams.  4/24 
grams  of  pig  lens  protein  injected  subcutaneously. 

August  27 :  Intradermal  tests  with  pig  and  ox  lens  protein  positive. 

September  19:  Discission  0.  D. 

September  21 :  Lens  markedly  cloudy.    Slight  pericorneal  congestion. 

September  26:  0.  D.  Discission  opening  closed.  Eye  quiet.  Second  dis- 
cission. 

October  1 :  0.  D.    Discission  opening  closed. 

October  5:  Third  discission  0.  D. 

October  8:  Pericorneal  congestion.  Iris  congested.  Posterior  synechia. 
Ball  of  cortical  matter  in  pupil.  Lens  becoming  vascular. 

October  11:  Intradermal  skin  test  with  pig  lens  protein  mildly  positive. 

October  15:  O.  D.    Fourth  discission.    O.  S.,  first  discission. 

October  20:  0.  D.  Pericorneal  congestion.  Slight  vascularization  of 
cornea  above.  Iris  congested.  A  few  vessels  invading  the  lens.  0.  S.,  no 
reaction. 

October  24:  O.  D.  Descemetitis.  Vascularization  of  the  cornea  prac- 
tically cleared.  There  is  an  artery  that  has  invaded  the  lower  part  of  the  lens. 
Iris  congested.  0.  S.  no  reaction. 

October  25:  Enucleation  O.  D. 

Microscopic  Examination. — Right  eye:  There  is  a  slight  infiltration  of  the 
tissues  of  the  limbus  with  lymphoid  and  plasma  cells.  Vessels  have  invaded 
the  periphery  of  the  cornea  for  a  distance  of  about  1J^  mm.  but  otherwise  the 
corneal  stroma  is  practically  normal.  There  are  a  few  mononuclear  cells 
attached  to  the  endothelium  of  the  cornea.  The  filtration  angle  is  free  in  most 
of  the  sections,  but  in  some  of  them  it  is  occluded  by  the  root  of  the  iris.  The 
uveal  meshes  are  slightly  infiltrated  with  lymphoid  cells.  The  iris  stroma,  in 
general,  shows  very  little  cellular  infiltration,  but  in  the  posterior  third,  in 
places,  there  is  a  considerable  number  of  plasma  cells. 


262  F.  H.  VERHOEFF  AND  A.  N.  LEMOINE 

A  rather  delicate  pupillary  membrane  which  is  continuous  with  the  iris  on 
one  side,  fills  the  pupil,  and  covers  the  gap  in  the  anterior  capsule.  This  gap 
is  only  about  0.15  mm.  wide.  The  anterior  capsule  is  swollen  and  greatly 
wrinkled.  Tissue  from  the  pupillary  membrane  accompanied  by  blood-vessels 
extends  through  the  gap  and  mingles  with  tissue  arising  from  the  capsular 
epithelium.  Just  beneath  this  membrane  the  lens  shows  a  large  area  of  lique- 
faction containing  numerous  hyaline  balls.  This  area  is  markedly  infiltrated 
with  endothelial  phagocytes,  many  of  which  are  collected  upon  and  phagocyt- 
ing  the  solid  portion  of  the  lens  substance  bordering  upon  it.  From  this  lique- 
fied area  there  extend  numerous  clefts  deeply  into  the  lens  substance,  some 
of  them  reaching  almost  to  the  posterior  capsule.  These  clefts  are  filled  with 
liquefied  lens  matter  markedly  infiltrated  with  pus-cells,  but  contain  few,  if 
any,  endothelial  phagocytes.  Many  of  the  pus-cells  are  necrotic.  Pus-cells 
are  also  found  in  the  comparatively  normal  lens  substance,  generally  lying  in 
small  vacuoles  which  they  have  evidently  produced.  The  capsular  epithelium 
has  extended  around  almost  the  entire  circumference  of  the  lens.  The  pos- 
terior capsule  shows  a  small  gap  which  has  been  closed  by  proliferation  of  the 
capsular  epithelium.  The  underlying  lens  substance  is  here  liquefied  and 
infiltrated  with  endothelial  phagocytes,  many  of  which  contain  pigment. 

The  ciliary  body  is  considerably  infiltrated,  chiefly  with  plasma  cells.  From 
its  surface  there  is  a  slight  exudation  of  lymphocytes. 

The  optic  disc  is  greatly  swollen  and  congested.  It  is  markedly  infiltrated 
with  lymphoid  and  plasma  cells,  the  latter  predominating.  From  the  porus 
there  is  taking  place  an  exudation  of  plasma  cells  into  the  vitreous.  An  exuda- 
tion of  these  cells  is  also  taking  place  from  the  retina  in  the  vicinity  of  the  disc. 
The  retina  is  edematous,  the  edema  being  most  marked  near  the  disc.  The 
choroid  is  practically  normal,  except  immediately  around  the  disc,  where,  on 
one  side,  it  is  markedly  infiltrated  with  plasma  cells  for  about  1^  mm.  The 
pigment  epithelium  at  this  margin  of  the  disc  shows  proliferative  changes. 

EXPERIMENT  4. — August  4,  1921.  Guinea-pig  weighing  400  grams.  4/24 
gram  of  pig  lens  protein  injected  subcutaneously. 

August  27:  Intradermal  skin  tests  with  pig  and  ox  lens  protein  both 
positive. 

September  19:  Discission  0.  D. 

September  21:  Lens  markedly  cloudy. 

September  26:  O.  D.  Discission  opening  closed.    Second  discission. 

October  1 :  O.  D.  Discission  opening  closed.    No  inflammatory  reaction. 

October  5:  O.  D.  Third  discission. 

October  8:  Lens  cloudy,  but  no  marked  reaction. 

October  11:  Intradermal  skin  test  with  pig  lens  protein  negative.  Dis- 
cission 0.  S. 

October  12:  4/24  gram  of  pig  lens  protein  injected  subcutaneously.  No 
immediate  symptoms  of  anaphylaxis. 


Endophihalmitis  Phacoanaphylactica 


263 


October  15:  No  reaction  from  the  injection  of  the  lens  protein.  Both  eyes 
free  from  congestion. 

EXPERIMENT  5  (Figs.  5  and  6). — August  4,  1921.  Guinea-pig  weighing  407 
grams.  4  /24  gram  of  pig  lens  protein  injected  subcutaneously. 

August  27 :  Intradermal  tests  with  pig  and  ox  lens  protein  both  positive. 

September  19:  Discission  0.  D. 


Fig.  5,  Exp.  5. — Right  eye  of  guinea-pig,  showing  marked  phacoanaphylactic 
endophthalmitis  eighteen  days  after  discission  of  lens.  Note  intense  involve- 
ment of  cornea.  (Photo  X  15.) 

September  21:  0.  D.  Marked  pericorneal  congestion.  Iris  congested. 
Posterior  synechia.  Lens  becoming  vascular. 

September  22 :  Eye  quieting. 

September  24:  About  the  same,  except  that  the  cornea  is  vascularized 
above  for  a  distance  of  1  mm. 

September  26:  Vascularization  of  lens  and  cornea.    Otherwise  eye  is  quiet. 


264 


F.  H.  VERHOEFF  AND  A.  N.  LEMOINE 


September  29:  Eye  practically  white.  Vessels  of  the  cornea  and  lens  dis- 
appearing. 

September  30:  0.  D.  Becoming  worse.  Pericorneal  congestion.  Iris  con- 
gested. Pupil  contracted.  Vessels  invading  the  cornea  all  around.  Vessels 
invading  the  lens. 

October  1:  O.  D.  The  cornea  is  completely  vascularized,  except  for  an  area 
of  about  2  mm.  in  the  center.  Edema  of  the  lids.  Slight  hypopyon. 

October  3 :  Circumcorneal  congestion  marked.  Cornea  slightly  more  vascu- 
lar. Marked  hypopyon.  Iris  congested.  Cornea  is  bulging.  Deep  anterior 
chamber. 


Fig.  6,  Exp.  5. — Right  eye.  Showing  tissue  from  pupillary  membrane 
extending  into  lens,  and  marked  infiltration  of  lens  substance  with  pus-cells. 
(Photo  X  50.) 

October  5:  0.  D.  Cornea  presents  about  the  same  condition.  Hypopyon 
not  so  marked. 

October  7:  Whole  cornea  is  vascular  and  bulging.  Hypopyon  about  the 
same.  Enucleation  0.  D.  Discission  O.  S. 

October  11:  Intradermal  test  with  pig  lens  protein  doubtful.  No  inflam- 
matory reaction  O.  S.  Lens  cloudy. 

Microscopic  Examination. — 0.  D.:  The  cornea  is  markedly  swollen,  being 
quadrupled  in  thickness  in  the  center.  The  epithelium  is  edematous,  the 
basal  cells  being  markedly  vacuolated.  At  one  place  there  is  an  intra-epithelial 
cyst,  0.45  mm.  in  diameter,  due  to  the  splitting  of  the  two  layers.  The  stroma 


Endophthalmitis  Phacoanaphylactica  235 

is  vascularized  to  an  extreme  degree  throughout,  so  that  it  resembles  granula- 
tion tissue.  There  is  marked  proliferation  of  the  corneal  corpuscles.  Anteri- 
orly it  shows  remarkably  slight  infiltration  with  pus-cells,  but  just  anterior  to 
Descemet's  membrane  the  infiltration  with  pus-cells  is  very  marked.  Here  too 
the  new  vessels  are  especially  large  and  the  tissue  especially  edematous.  In 
two  places  Descemet's  membrane  has  been  destroyed,  apparently  by  the  pus- 
cells  within  the  cornea,  and  the  gap  filled  by  actively  proliferating  epithelioid 
cells.  There  are  numerous  hemorrhagic  extravasations  in  the  stroma,  the 
largest  one  being  just  in  front  of  the  posterior  surface.  The  endothelium  is 
intact,  but  it  is  thickened  by  proliferation.  It  is  covered  by  a  layer  of  pus  and 
red  blood-cells  which  is  thin  above  and  gradually  becomes  thicker  as  the  lower 
angle  is  approached.  At  the  lower  angle  it  assumes  the  character  of  a  hy- 
popyon  3  mm.  high  consisting  chiefly  of  pus-cells.  The  hypopyon  also  con- 
tains a  considerable  number  of  mononuclear  cells,  endothelial  phagocytes,  and 
blood-corpuscles.  The  filtration  angle  is  completely  closed  off  by  a  wide 
peripheral  synechia.  The  pupillary  area  is  filled  with  dense  vascular  mem- 
brane, rich  in  fibroblasts,  which  is  continuous  with  a  similar  richly  vascularized 
membrane  that  replaces  the  anterior  surface  of  the  iris  everywhere.  The  iris 
stroma  is  moderately  infiltrated  with  plasma  and  lymphoid  cells  in  the  pos- 
terior part;  as  the  anterior  surface  is  approached  these  cells  are  markedly  in- 
creased in  number.  Incorporated  within  the  pupillary  membrane  are  several 
large  masses  of  cortical  substance.  These  are  surrounded  by  endothelial 
phagocytes  and  invaded  to  some  extent  by  pus-cells.  The  anterior  capsule  of 
the  lens  shows  a  gap  1  mm.  wide  which  is  filled  in  by  the  pupillary  membrane. 
The  latter,  however,  does  not  extend  deeply  into  the  lens.  At  each  margin  of 
the  gap  the  capsular  epithelium  has  proliferated  and  formed  a  large  mass  of 
tissue  which  fuses  with  the  pupillary  membrane.  Immediately  behind  the 
tissue  filling  the  gap  in  the  capsule  the  lens  substance  is  liquefied  and  is  being 
invaded  by  pus-cells.  The  solid  lens  matter  bordering  this  liquefied  area 
behind  is  coated  with  many  endothelial  phagocytes,  and  is  markedly  infil- 
trated with  pus-cells  which  in  places  are  collected  in  large  masses.  On  one  side 
the  infiltration  extends  almost  to  the  equator  of  the  lens,  through  more  than 
half  its  thickness.  The  capsular  epithelium  has  not  extended  posteriorly,  and 
is  normal  except  at  the  site  of  the  discission. 

The  ciliary  body  is  congested,  edematous,  and  infiltrated  chiefly  with 
plasma  cells.  The  anterior  portion  contains  a  considerable  number  of  endo- 
thelial phagocytes  many  of  which  are  pigmented.  The  plasma  cell  infiltration 
is  largely  nodular  in  character  and  extends  as  far  back  as  the  ora  serrata.  The 
ciliary  processes  are  giving  off  a  moderate  number  of  large  and  small  lympho- 
cytes and  a  few  pus-cells.  Very  few  cells  are  being  given  off  by  the  pars 
plana.  The  optic  disc  shows  edema  and  congestion,  but  no  significant  cellular 
infiltration.  The  choroid  and  retina  are  practically  normal. 


266  F.  H.  VERHOEFF  AND  A.  N.  LEMOINE 

EXPERIMENT  6. — -August  27, 1921 .  Guinea-pig  weighing  310  grams.  Intra- 
dermal  tests  with  pig  and  ox  lens  protein  negative. 

August  30:  Discission  0.  D. 

August  31 :  O.  D.   Lens  cloudy.    No  inflammatory  reaction. 

September  1 :  0.  D.   No  reaction. 

September  13:  Discission  opening  closed. 

September  14:  Second  discission  O.  D. 

September  16:  Marked  reaction.  Lids  slightly  swollen.  Lens  cloudy. 
Pericorneal  congestion.  Iris  congested. 

September  18 :  Eye  clearing  up,  but  lens  vascular.  Slight  vascularization  of 
cornea  above. 

September  21 :  Posterior  synechia.  Anterior  surface  of  lens  vascular.  Skin 
test  with  pig  lens  protein  mildly  positive. 

September  26:  Discission  opening  not  visible.    Pupil  contracted. 

October5:  Vessels  in  the  lens  disappearing.    Eye  white  and  quiet. 

October  11:  Iris  slightly  discolored  and  congested.  Slight  pericorneal  con- 
gestion. 

October  15:  Slight  vascularization  of  the  periphery  of  the  cornea.  Vessels 
in  anterior  surface  of  the  lens  more  marked. 

November  25:  Eye  white  and  quiet.    Enucleation  0.  D. 

Microscopic  Examination. — 0.  D.:  The  cornea  appears  normal  except  that 
it  is  vascularized  with  a  few  small  vessels  which  have  invaded  the  whole  cornea 
except  an  area  2  mm.  in  diameter  in  the  center.  The  root  of  the  iris  closes  off 
the  filtration  angle  all  around.  At  the  angle  the  uveal  meshes  are  slightly 
infiltrated  with  plasma  and  lymphoid  cells. 

The  pupillary  margin  is  connected  with  one  of  the  discission  wounds  by  a 
long  thin  strand,  rich  in  connective-tissue  cells.  The  pupillary  area  is  filled  by 
a  delicate  vascular  membrane  which  is  continuous  with  the  pupillary  margin 
of  the  iris  and  adherent  to  the  markedly  wrinkled  lens  capsule.  This  mem- 
brane in  its  anterior  half  is  densely  infiltrated  with  plasma  cells.  The  iris  is 
moderately  congested  and  greatly  infiltrated  with  plasma  cells.  The  lens 
capsule  shows  a  gap  1A  mm.  in  diameter  near  the  periphery  of  the  anterior  sur- 
face. This  gap  is  covered  by  the  iris.  The  epithelium  has  disappeared  from 
immediately  beneath  the  anterior  lens  capsule,  except  for  slight  stretches  here 
and  there.  Beneath  the  capsule  there  is  a  wide  space  filled  with  delicate 
avascular  tissue  which  is  slightly  infiltrated  with  plasma  cells  and  pervaded 
by  strands  of  cells  derived,  evidently,  from  the  capsular  epithelium.  Border- 
ing this  space  posteriorly,  except  for  an  area  in  the  center,  and  closely  applied 
to  the  lens  substance,  is  a  layer  of  epithelium  similar  to  that  of  a  normal  lens 
capsule.  At  the  periphery  on  one  side  this  layer  is  continuous  with  the  normal 
capsular  epithelium  which  is  here  intact.  On  the  other  side  the  lens  capsule 
is  separated  still  further  from  the  lens  substance  and  is  adherent  in  places  to 
the  ciliary  processes.  The  posterior  surface  of  the  lens  is  denuded  of  capsule 


Endophthalmitis  Phacoanaphylactica  267 

and  coated,  except  for  a  small  area  at  the  posterior  pole,  by  a  layer  of  epithe- 
lium continuous  with  that  coating  the  anterior  surface.  This,  in  turn,  is 
coated  by  a  very  delicate  but  thick  layer  of  tissue  similar  to  that  beneath  the 
anterior  capsule,  which,  like  the  latter,  is  pervaded  by  epithelial  strands.  In 
some  sections  this  tissue  continues  over  the  intact  capsule  at  the  periphery 
and  becomes  adherent  to  the  ciliary  processes.  It  also  becomes  continuous 
with  the  tissue  beneath  the  anterior  capsule.  In  places  a  few  blood-vessels 
may  be  seen  within  it,  indicating  that  it  really  represents  a  cyclitic  membrane 
pervaded  by  epithelial  strands  derived  from  the  ciliary  epithelium.  The  lens 
substance  is  reduced  to  less  than  one-half  its  normal  thickness,  evidently  by 
absorption.  Its  central  portion  is  comparatively  normal,  but  the  cortex 
laterally  is  everywhere  cataractous,  and  is  largely  converted  into  bladder  cells. 
The  central  portion  of  the  anterior  surface  is  coated  by  proliferated  capsular 
epithelium  beneath  which  is  an  almost  continuous  layer  of  endothelial 
phagocytes  some  of  which  have  formed  giant  cells.  The  comparatively  nor- 
mal lens  substance  is  infiltrated  to  a  slight  extent  with  pus-cells,  many  of 
which  are  necrotic,  while  the  cortex  in  places  contains  numbers  of  endothelial 
phagocytes.  At  the  posterior  pole  the  capsular  epithelium  has  formed  a  tissue 
similar  to  that  of  a  capsular  cataract,  through  which  endothelial  phagocytes 
are  entering  the  lens. 

The  ciliary  body  is  congested  and  shows  considerable  infiltration  with 
plasma  cells  which  have  a  tendency  to  appear  in  nodules  some  of  which  are 
as  far  back  as  the  ora  serrata.  The  surface  of  the  processes  is  giving  off  a 
slight  exudate  containing  lymphoid  and  large  mononuclear  cells.  The  cyclitic 
membrane  described  above  is  no  longer  in  active  formation. 

The  optic  disc  is  greatly  swollen,  and  shows  moderate  infiltration  with 
lymphoid  cells  and  considerable  neuroglia  proliferation.  From  its  surface 
there  is  some  exudation  of  lymphoid  and  plasma  cells.  The  retina  shows 
slight  edema  and  slight  exudation  of  plasma  and  lymphoid  cells  from  its  sur- 
face for  a  considerable  distance  from  the  disc.  At  the  margin  of  the  disc  the 
choroid  is  considerably  infiltrated  with  plasma  cells,  scattered  foci  of  which 
also  can  be  seen  as  far  forward  as  the  equator. 

EXPERIMENT  7. — November  25,  1921.  Guinea-pig  weighing  370  grams. 
4  /24  gram  fresh  pig  lens  protein  injected  subcutaneously. 

December  15:  Discission  0.  D. 

December  16:  0.  D.:  Slight  pericorneal  congestion.  Pupil  well  dilated. 
Lens  matter  in  pupil. 

December  18:  0.  D.:  Slight  pericorneal  congestion.  Pupil  not  completely 
dilated.  Iris  congested.  Lens  cloudy  at  point  of  discission  and  on  posterior 
surface. 

December  20:  0.  D.:  Pericorneal  congestion.  Pupil  contracted.  Photo- 
phobia. O.  S.  is  dilated  to  maximum  (as  a  result  of  transference  of  atropin 
from  0.  D.). 


268  F.  H.  VERHOEFF  AND  A.  N.  LEMOINE 

December  21:  0.  D.:  Pericorneal  congestion  quite  marked.  Pupil  con- 
tracted to  \y<t  mm.  Iris  congested.  0.  S.  widely  dilated.  Discission  0.  S. 

December  22:  0.  D.:  Pericorneal  congestion.  Iris  congested.  Pupil  still 
contracted.  O.  S.:  Chemosis  and  congestion  of  conjunctiva.  Pupil  com- 
pletely dilated.  Lens  cataractous,  and  a  mass  of  cortical  matter  projects 
through  the  opening  in  the  capsule. 

December  23 :  0.  D. :  No  change.  0.  S. :  Chemosis  of  conjunctiva  marked. 
Ciliary  congestion.  Pupil  beginning  to  contract. 

December  24:  0.  D.:  Pericorneal  congestion  not  so  marked.  Pupil  con- 
tracted. Lens  cataractous.  0.  S. :  Chemosis  of  conjunctiva  about  the  same. 
Pericorneal  congestion  marked.  Iris  congested.  Pupil  more  contracted. 
Photophobia. 

December  25:  0.  D. :  Pericorneal  congestion  not  so  marked.  Iris  and  pupil 
about  the  same.  O.  S. :  About  the  same,  except  that  the  pupil  is  more  con- 
tracted. Enucleation  O.  U. 

Microscopic  Examination. — 0.  D.:  The  cornea  is  considerably  edematous 
and  infiltrated  with  pus-cells  and  shows  beginning  vascularization.  Its  pos- 
terior surface  is  coated  with  lymphocytes.  The  anterior  chamber  is  filled  with 
serum.  There  is  an  anterior  peripheral  synechia  on  one  side.  The  iris  is  ad- 
herent at  the  pupillary  margin  on  one  side  to  the  discission  wound  in  the  lens, 
and  is  congested,  but  it  is  very  slightly  infiltrated. 

The  discission  wound  passes  entirely  through  the  lens.  The  gap  in  the 
anterior  capsule  is  solidly  closed  by  a  mass  of  cells  derived  from  the  capsular 
epithelium,  and  the  latter  is  markedly  proliferated  for  a  considerable  distance 
on  each  side  of  the  gap.  The  gap  in  the  posterior  capsule  is  4  mm.  wide  and 
through  it  the  lens  bulges  into  the  vitreous. 

The  lens  is  highly  cataractous  along  the  path  of  the  discission  wound,  the 
cataractous  changes  being  more  marked  as  the  gap  in  the  posterior  capsule  is 
approached.  The  lens  substance  is  greatly  infiltrated  with  pus-cells,  many  of 
which  are  necrotic,  the  infiltration  is  most  marked  posteriorly.  Pus-cells  are 
also  collected  in  abundance  on  the  posterior  surface  of  the  cataractous  lens, 
and  it  is  evidently  from  here  that  the  infiltration  of  the  lens  is  chiefly  taking 
place. 

The  vitreous  humor  is  rich  in  serum  and  is  greatly  infiltrated  with  pus-cells 
which  become  more  and  more  numerous  as  the  gap  in  the  posterior  capsule  is 
approached. 

From  the  surface  of  the  ciliary  body  there  is  taking  place  an  exudation  of 
pus-cells,  lymphocytes,  and  endothelial  phagocytes.  The  retina  and  choroid 
seem  practically  normal.  The  optic  disc  is  congested  and  edematous  and  is 
giving  rise  to  a  slight  exudation  of  pus-cells  and  lymphocytes. 

0.  S. :  The  cornea  is  slightly  vascularized  at  the  periphery,  but  is  almost 
free  from  infiltration.  There  are  a  few  lymphocytes  on  the  posterior  surface. 
The  anterior  chamber  is  filled  with  serum.  The  filtration  angle  is  free.  The 


Endophthalmitis  Phacoanaphylactica  269 

iris  is  only  slightly  infiltrated  but  shows  numerous  lymphocytes  and  a  few 
endothelial  phagocytes  on  its  surface. 

The  discission  wound  in  the  lens  is  very  small  and  does  not  reach  the  pos- 
terior capsule.  The  gap  in  the  anterior  capsule  is  only  0.2  mm.  wide  and  is 
solidly  closed  by  a  mass  of  cells  derived  from  the  capsular  epithelium  to  which 
the  iris  is  adherent.  The  lens  substance  along  the  path  of  the  discission  wound 
is  cataractous  and  greatly  infiltrated  with  pus-cells  which  are  undergoing 
necrosis. 

The  ciliary  body,  especially  the  orbiculus,  is  giving  off  a  moderate  exudate 
of  small  and  large  lymphocytes.  The  vitreous  is  infiltrated  with  serum  and 
contains  large  clumps  of  necrotic  large  mononuclear  cells. 

The  retina  shows  slight  edema.  The  choroid  is  normal.  The  optic  disc  is 
slightly  swollen.  • 

EXPERIMENT  8  (Control). — October  10,  1921.  Guinea-pig  weighing  410 
grams.  Discission  O.  S. 

October  12:  Lens  swollen  and  cloudy.  No  inflammatory  reaction.  Enu- 
cleation  0.  S. 

Micr.oscopic  Examination. — 0.  S.:  The  cornea  shows  a  very  slight  infiltra- 
tion with  pus-cells.  Attached  to  the  posterior  surface  there  is  an  occasional 
lymphocyte.  The  filtration  angle  is  open.  The  iris,  ciliary  body,  retina,  and 
optic  disc  are  normal.  The  pupil  is  widely  dilated.  There  is  a  gap  2J4  mm. 
in  the  anterior  capsule  of  the  lens  through  which  lens  substance  protrudes 
forming  a  nodule  ^  mm.  high.  Along  the  surface  the  nodule  is  slightly 
cataractous.  It  is  coated  with  a  layer  of  delicate  fibrin  which  contains  an 
occasional  lymphocyte.  The  capsular  epithelium  at  the  margin  of  the  gap  is 
undergoing  proliferation  and  beginning  to  extend  over  the  surface  of  the  pro- 
truding nodule.  The  cataractous  lens  matter  at  the  periphery  of  the  nodule 
contains  very  few  cells.  The  cells  have  round  or  oval  nuclei  and  their  cell 
bodies  are  swollen.  They  certainly  are  not  pus-cells  and  possibly  have 
migrated  from  the  capsular  epithelium.  The  solid  lens  substance  is  abso- 
lutely free  from  cellular  infiltration. 

EXPERIMENT  9  (Control,  Figs.  7  and  8). — September  21,  1921.  Guinea- 
pig  weighing  440  grams.  Discission  0.  D. 

September  24 :  Eye  white  and  quiet.    Lens  cloudy. 

September  26 :  Discission  opening  in  capsule  closed.  Second  discission 
0.  D. 

September  29 :  Eye  white.    Lens  cloudy. 

October  1 :  Discission  opening  closed.  Lens  cataractous  at  posterior  pole 
only. 

October  5:  Third  discission  0.  D. 

OctoberS:  0.  D.:  Eye  quiet.    No  congestion.    Lens  cloudy. 

October  10:  O.  D.:  Eye  quiet.    Discission  opening  closed.    Discission  0.  S. 

October  12:  Both  eyes  quiet.    Lenses  cloudy. 


270 


F.  H.  VERHOEFF  AND  A.  N.  LEMOINE 


Fig.  7,  Exp.  9. — (Control.)  Showing  discission  wound  nine  days  after 
third  discission  in  right  eye  of  non-sensitized  guinea-pig.  The  wound  is  closed  by 
proliferation  of  the  capsular  epithelium  and  the  iris  on  one  side  only  is  lightly 
adherent  to  the  mass  of  tissue  thus  formed.  The  lens  substance  is  free  from 
infiltration.  (Photo  X  75.) 


Fig.  8,  Exp.  9. — (Control.)  Showing  lens  changes  four  days  after  discission 
of  left  lens  of  non-sensitized  guinea-pig.  The  protruding  nodule  is  coated  with  a 
delicate  layer  of  fibrin  and  a  few  cells  derived  from  the  capsular  epithelium,  but 
is  free  from  infiltration  with  pus-cells.  (Photo  X  75.) 


Endophthalmitis  Phacoanaphylactica  271 

October  14:  No  change.    Enucleation  0.  U. 

Microscopic  Examination. — 0.  D.:  The  cornea  is  absolutely  normal.  The 
anterior  chamber  contains  a  trace  of  serum.  Filtration  angle  open.  The  iris, 
ciliary  body,  and  retina  are  free  from  infiltration.  The  optic  disc  is  possibly 
slightly  swollen  and  shows  a  small  interstitial  hemorrhage,  but  is  free  from 
cellular  infiltration.  An  occasional  lymphocyte  may  be  seen  upon  the  surface 
of  the  cilary  body.  The  capsule  of  the  lens  shows  a  gap  about  %  mm.  wide. 
This  is  completely  closed  by  a  thick  mass  of  tissue  rich  in  cells,  due  to  pro- 
liferation of  the  capsular  epithelium.  The  pupillary  margin  is  slightly  ad- 
herent to  this  mass.  The  underlying  lens  substance  is  moderately  cataractous 
for  a  microscopic  distance,  and  infiltrated  to  a  slight  extent  with  free  cells 
from  the  capsular  epithelium  which  are  undergoing  necrosis,  but  is  free  from 
pus-cells.  The  posterior  capsule  is  ruptured  and  the  lens  substance  pos- 
teriorly has  swollen  to  such  an  extent  that  it  has  enlarged  the  gap  in  the 
capsule  to  a  width  of  4  mm.  The  peripheral  portion  of  the  lens  thus  exposed 
is  highly  cataractous,  being  liquefied  and  broken  up  into  hyaline  balls.  The 
lens  substance  bordering  on  the  cataractous  portion  contains  an  abnormal 
number  of  nuclei,  apparently  produced  by  proliferation  of  the  nuclei  of  the 
lens  fibers,  but  is  free  from  cellular  infiltration,  as  is  also  the  cataractous  por- 
tion of  the  posterior  cortex.  The  vitreous  is  infiltrated  with  serum,  but  is  free 
from  cellular  infiltration. 

O.  S. :  Except  for  the  lens,  the  eye  is  normal.  The  lens  capsule  shows  a  gap 
0.7  mm.  wide  through  which  the  lens  substance  protrudes  in  the  form  of  a 
nodule  about  0.5  mm.  in  height.  Along  its  surface  the  nodule  is  broken  up 
into  hyaline  balls  which  are  covered  by  a  thin  layer  of  fibrin.  The  capsular 
epithelium  has  proliferated  and  extended  as  an  irregular  layer  of  cells  for  a 
short  distance  over  the  surface  of  the  nodule.  The  anterior  surface  of  the 
fibrin  shows  an  occasional  thin,  elongated  cell  with  an  ovoid  nucleus.  The 
substance  of  the  nodule  is  infiltrated  very  slightly  with  free  cells  apparently 
derived  from  the  capsular  epithelium,  many  of  which  show  fragmentation  of 
their  nuclei.  The  main  lens  substance  is  apparently  normal. 

EXPERIMENT  10  (Control). — August  27,  1921.  Guinea-pig  weighing  380 
grams.  Intradermal  tests  with  pig  and  ox  lens  protein  negative. 

September  19:  Discission  0.  D.  The  animal  made  a  sudden  movement  and 
the  knife  went  entirely  through  the  lens,  causing  a  large  hemorrhage  in  the 
vitreous. 

September  21:  Lens  cloudy.    No  inflammatory  reaction. 

September  24:  Discission  opening  closed.    No  reaction. 

September  26:  Second  discission  0.  D. 

September  27 :  No  reaction  0.  D.    Skin  test  with  pig  lens  protein  doubtful. 

October  1 :  Discission  opening  closed.  Lens  cataractous  in  posterior  por- 
tion only. 

October  5:  Third  discission. 


272  F.  H.  VERHOEFF  AND  A.  N.  LEMOINE 

October  8:  Eye  quiet.    Lens  cloudy.    No  reaction. 

December  5 :  At  no  time  has  the  animal  had  any  intraocular  inflammation. 
0.  D.:  Enucleation. 

Microscopic  Examination. — The  cornea  and  iris  are  normal.  There  is  no 
peripheral  anterior  synechia,  posterior  synechia,  or  pupillary  membrane.  The 
discission  wound  in  the  anterior  capsule  is  closed  by  proliferation  of  the  capsu- 
lar  epithelium.  The  underlying  lens  substance  appears  normal  for  a  con- 
siderable distance,  then  cataractous  changes  may  be  seen  along  the  path  of 
the  discission  wound.  Here  also,  deep  in  the  lens,  there  are  a  few  small  col- 
lections of  cells  which  are  so  necrotic  that  their  nature  cannot  be  determined. 
Just  behind  the  equator  on  one  side  the  posterior  capsule  shows  a  wide  gap 
and  the  lens  substance  is  coated  by  a  thick  layer  of  spindle-cells  which  is  con- 
tinuous with  the  capsular  epithelium  at  the  equator.  Beneath  this  the  lens 
substance  shows  numerous  bladder  cells.  Upon  the  posterior  surface  of  the 
lens  there  is  a  moderate  amount  of  blood  which  has  attracted  a  few  endothelial 
phagocytes  and  lymphocytes.  The  ciliary  body  is  free  from  infiltration,  but 
on  the  side  nearest  the  gap  in  the  posterior  lens  capsule  it  is  coated  with  a 
small  amount  of  blood.  From  its  surface  there  is  a  slight  exudation  of  endo- 
thelial phagocytes  and  lymphocytes  which  evidently  have  been  attracted  by 
the  blood. 

The  choroid  and  retina  are  normal.  The  physiologic  cup  of  the  optic  disc 
is  filled  with  lymphocytes  and  endothelial  phagocytes.  Some  of  the  latter 
contain  blood  pigment,  indicating  that  the  presence  of  these  cells  is  the  result 
of  the  hemorrhage  in  the  vitreous. 

EXPERIMENT  11. — December  10,  1921.  Guinea-pig:  Discission  O.  D.  The 
cornea  about  the  discission  wound  immediately  became  cloudy  from  infiltra- 
tion with  aqueous  humor. 

December  12:  No  pericorneal  congestion.  No  inflammatory  reaction. 
Cornea  cloudy  about  the  wound.  Pupil  well  dilated.  Lens  cloudy. 

December  13:  0.  D.  Eye  quiet  and  white.  Cornea  still  cloudy.  Pupil 
completely  dilated.  Discission  0.  S. 

December  14:  0.  D.  Eye  quiet.  Pupil  completely  dilated.  Cornea  the 
same.  Lens  slightly  cloudy.  O.  S.  No  congestion.  Pupil  dilated  to  maxi- 
mum. Slight  cloudiness  of  the  lens  with  a  mass  of  cortical  substance  pro- 
truding into  the  anterior  chamber. 

December  15:  0.  D.  Cloudiness  of  cornea  practically  gone.  Eye  quiet. 
0.  S.  Eye  quiet. 

December  19:  Both  eyes  white  and  quiet.  Discission  opening  appears 
closed.  Lens  matter  in  anterior  chamber  0.  S.  completely  absorbed.  Both 
pupils  dilated  to  maximum. 

December  21 :  Both  eyes  quiet.    Pupils  still  dilated. 

December  23 :  No  change.    Enucleation  0.  U. 

Microscopic  Examination. — 0.  D. :  The  discission  wound  is  closed  by  a  mass 


Endophthalmitis  Phacoanaphylactica  273 

of  cells  continuous  with  and  evidently  derived  from  the  capsular  epithelium. 
The  lens  substance  is  free  from  infiltration  with  pus-cells  or  endothelial 
phagocytes.  The  condition  is  essentially  the  same  as  in  Exp.  9  (Fig.  5),  but 
the  iris  is  not  adherent  to  the  lens.  The  lens  substance  shows  only  slight 
cataractous  changes,  repair  evidently  having  taken  place.  The  eye  is  other- 
wise normal. 

0.  S. :  The  gap  in  the  capsule  is  0.75  mm.  wide  and  is  filled  in  by  a  mass  of 
epithelial  cells  through  the  center  of  which  a  strand  of  lens  substance  still 
projects.  The  iris  is  adherent  to  this  mass.  The  underlying  lens  substance  is 
slightly  cataractous  and  slightly  infiltrated  with  free  epithelial  cells,  most  of 
which  are  necrotic.  There  is  no  infiltration  with  pus-cells.  The  eye  is  other- 
wise normal. 

EXPERIMENT  12. — November  25,  1921. :  4  /24  gram  pig  lens  protein  injected 
subcutaneously. 

December  15:  4.20  P.M.  4/24  gram  pig  lens  protein  injected  subcutane- 
ously. 


4.22  P.  M. 
4.24  P.  M. 
4.30  P.  M. 


to  stand  erect. 


4.35  P.  M. 
5.20  P.  M. 


still  stands  erect. 


7.30  P.  M. 


Animal  is  restless. 

Animal  quiet  and  appears  very  sick. 

Animal  cuddles  up  to  other  animals  as  if  cold.    The  hair  begins 


Has  difficulty  in  standing  and  incontinence  of  urine. 

Still  has  incontinence  of  urine  and  difficulty  in  standing.    Hair 


Animal  walks  about,  but  hair  is  now  erect  on  the  face  so  that 


eyes  appear  sunken.    Marked  lacrimation. 

10.30  P.  M.:  Animal  able  to  walk  about  and  hair  not  so  erect. 

December  16,  1921,  7.30  A.  M.:  Animal  appears  normal  except  that  the  hair 
is  slightly  erect. 

EXPERIMENTS  ON  RABBITS 

Discissions  of  the  lenses  were  made  in  the  eight  eyes  of  four  ani- 
mals. In  two  of  the  animals  the  discissions  were  made  twenty-one 
days  after  subcutaneous  injection  of  1/24  gm.  of  fresh  pig  lens  protein 
per  100  gm.  of  body  weight.  The  eye  of  one  of  the  control  animals 
was  infected,  and  is  therefore  excluded  from  consideration.  Clinic- 
ally, the  intraocular  reactions  were  definitely  greater  in  the  treated 
animals  than  in  the  controls,  but  in  the  latter  were  greater  than  in 
control  guinea-pigs.  Histologically,  the  reactions  were  also  more 
marked  in  the  injected  animals  than  in  the  controls,  but  did  not  show 
the  characteristic  features  seen  in  hypersensitive  guinea-pigs  and 
human  individuals.  For  this  reason  we  omit  the  detailed  protocol 
18 


274  F.  H.  VERHOEFF  AND  A.  N.  LEMOINE 

of  these  experiments.  Possibly  sensitization  by  repeated  small  doses 
of  lens  protein  might  give  more  characteristic  results. 

The  foregoing  clinical  observations,  tests,  and  microscopic  ex- 
aminations prove  conclusively  that  certain  individuals  are  hyper- 
sensitive to  lens  protein,  and  that  when  in  such  individuals  rupture 
of  the  lens  capsule  takes  place  through  injury  or  operation  or  spon- 
taneously, a  characteristic  inflammatory  reaction  results.  This 
reaction  may  properly  be  termed  endophthalmitis  phacoanaphy- 
lactica.1  Whether  or  not  hypersensitiveness  to  lens  protein  is  con- 
genital or  acquired,  and  if  the  latter,  how  it  is  acquired,  we  have  at 
present  insufficient  data  to  determine.  While  experimentally  it  is 
possible  to  sensitize  an  animal  to  its  own  lens  protein,  the  evidence  is 
against  the  possibility  that  injury  to  the  lens  of  one  eye  may  sensitize 
an  individual  so  that  a  local  anaphylactic  reaction  will  take  place  if 
the  other  lens  is  injured.  The  clinical  fact  that  in  cases  of  congenital 
cataract  discission  of  the  cataract  in  the  second  eye  ordinarily  causes 
no  greater  reaction  than  that  following  discission  of  the  cataract  in  the 
first  eye  seems  to  be  sufficiently  conclusive  on  this  point.  Possibly  in 
these  cases  absorption  of  lens  matter  slowly  and  continuously  over  a 
long  period  of  time,  if  it  has  any  effect,  may  cause  immunity  rather 
than  hypersensitiveness. 

Our  experiments  upon  animals  seem  to  show  that  a  guinea-pig  may 
be  sensitized  to  lens  protein  so  that  a  free  discission  of  its  lens  capsule 
will  be  followed  by  a  severe  and  characteristic  intraocular  reaction. 
That  the  dosage  of  lens  protein  employed  was  sufficient  to  sensitize 
the  animals  is  shown  by  the  skin  tests  and  also  by  Exp.  12  in  which  a 
second  subcutaneous  injection  made  20  days  after  the  first  caused 
marked  general  symptoms  of  anaphylaxis.  Histologically  the  ocular 
reaction  differs  from  that  in  human  individuals  only  in  the  extent  to 
which  the  cornea  is  affected,  the  latter,  in  the  case  of  the  guinea-pigs, 
showing  marked  haziness  and  vascularization.  In  Experiments  2 
and  5  the  cornea  became  almost  completely  vascularized.  It  is  to 
be  noted,  however,  that  in  one  of  our  clinical  cases,  Case  1,  the  cornea 
became  almost  completely  vascularized.  In  our  control  experiments 
the  intraocular  reaction  following  discission  of  the  lens  was  not  only 
slight,  but  differed  in  character  from  that  seen  in  a  sensitized  animal. 
As  already  pointed  out,  one  animal  (Exp.  6)  intended  as  a  control, 
became  sensitized  by  an  intradermal  test  and, gave  a  phacoanaphy- 

1  Endophthalmitis  phacoallergica  may  be  a  better  term,  but  probably  it  would 
not  be  generally  understood. 


Endophthalmitis  Phacoanaphylactica  275 

lactic  reaction  following  discission  of  the  lens.  In  Experiments  2,  3 
and  5  no  reaction  followed  discission  of  the  lens  of  the  second  eye  made 
19  to  26  days  after  discission  of  the  lens  of  the  first  eye.  It  is  probable 
either  that  these  animals  had  become  immunized  as  a  result  of  the 
first  discissions  and  intradermal  tests,  or  that  sufficient  time  had 
elapsed  for  the  hypersensitiveness  to  have  disappeared,  for  in  Exp.  2, 
a  negative,  in  Exp.  3,  a  mildly  positive,  and  in  Exp.  5,  a  doubtful 
intradermal  reaction  was  subsequently  obtained.  In  Exp.  4  no  in- 
flammatory reaction  followed  discissions  of  the  lenses  of  an  animal 
supposed  to  be  hypersensitive,  but  in  this  experiment  an  intradermal 
test  made  later  was  negative,  and  the  animal  failed  to  show  any 
general  symptoms  of  anaphylaxis  after  a  subcutaneous  injection  of 
lens  protein. 

As  Longcope8  has  recently  pointed  out,  in  human  individuals  the 
state  of  hypersensitiveness  to  foreign  proteins  shows  certain  differ- 
ences from  that  produced  experimentally  in  animals,  and  he  raises  the 
question  whether  it  is  based  upon  the  same  mechanism.  In  this  con- 
nection he  calls  attention  to  the  familiar  occurrence  of  hypersensi- 
tiveness to  certain  proteins  in  human  individuals,  which  suggests 
that  inheritance  is  an  important  factor,  and  to  the  rarity  with  which 
specific  antibodies  are  found  in  the  serum  of  these  individuals. 
Whether  or  not,  however,  there  is  an  important  difference  between 
the  mechanisms  of  natural  and  artificially  produced  anaphylaxis, 
the  clinical  effects  seem  to  be  essentially  the  same,  and  our  experi- 
ments on  guinea-pigs,  as  just  noted,  seem  to  show  that  in  animals 
sensitized  to  lens  protein  the  intraocular  reaction  produced  by  injury 
to  the  lens  is  microscopically  identical  with  that  in  human  individuals. 
It  has  been  frequently  noted  that  immune  and  anaphylactic  reactions 
of  rabbits  are  markedly  different  from  those  of  guinea-pigs,  and 
Zinsser9  has  recently  pointed  out  the  close  similarity  of  such  reactions 
in  guinea-pigs  and  human  individuals.  The  former  fact  no  doubt 
explains  our  failure  to  produce  typical  phacoanaphylactic  endoph- 
thalmitis  in  rabbits,  and  the  latter  fact  is  confirmed  and  amplified 
by  the  positive  results  of  our  experiments  on  guinea-pigs. 

The  clinical  picture  of  phacoanaphylactic  endophthalmitis  is  fairly 
characteristic,  especially  in  marked  cases.  In  the  beginning  there  is 
simply  iritis  with  posterior  synechia.  From  the  pupillary  margin  a 
vascularized  membrane  extends  over  the  injured  lens.  At  the  same 
time  the  lens  matter  becomes  infiltrated  until  it  presents  an  opaque, 
finely  granular  appearance.  At  this  stage  precipitates  may  be  found 


276  F.  H.  VERHOEFF  AND  A.  N.  LEMOINE 

on  the  posterior  surface  of  the  cornea.  These  are  apt  to  be  unusually 
large  and  white  in  appearance.  Sometimes  a  small  hypopyon  is 
formed.  If  the  process  continues,  the  cornea  becomes  cloudy  and 
progressively  vascularized.  The  intraocular  tension  is  apt  to  be  in- 
creased. Pain  and  congestion  of  the  eye  vary  with  the  activity  of 
the  process  and  are  sometimes  relatively  slight. 

To  make  the  diagnosis  certain,  dermal  and  intradermal  tests  with 
lens  protein  should,  of  course,  be  employed  in  all  cases. 

Our  observations  concerning  the  histology  of  phacoanaphylactic 
endophthalmitis  are  sufficiently  summarized  above,  but  we  ma,y  point 
out  here  that  the  invasion  of  the  lens  substance  by  pus-cells  seems  to 
be  especially  characteristic,  particularly  as  regards  the  relatively 
normal  portion.  In  other  words,  in  hypersensitive  individuals 
exposed  lens  matter  is  pyogenic.  We  should,  in  fact,  hesitate  to 
make  a  diagnosis  of  phacoanaphylactic  inflammation  histologically, 
in  the  absence  of  any  purulent  infiltration  of  the  lens.  The  severity 
of  the  intraocular  reaction  depends  largely  on  the  extent  of  the  gap 
in  the  lens  capsule  and  upon  the  amount  of  lens  substance  that  is 
extruded  into  the  anterior  chamber  or  vitreous.  When  the  gap  in 
the  capsule  is  so  situated  that  access  of  lens  matter  to  the  vitreous  is 
early  cut  off  by  adhesion  of  the  iris  to  the  lens,  the  reaction  is  confined 
chiefly  to  the  anterior  part  of  the  eye,  notably  the  iris.  When  the 
lens  matter  accumulates  in  the  vitreous  chamber,  cyclitis  results, 
and  may  lead  to  the  formation  of  dense  cyclitic  membranes.  In  this 
event  also  the  retina  and  optic  disc  may  be  markedly  affected.  When 
the  defect  in  the  lens  capsule  is  covered  over  by  organized  tissue 
derived  from  the  iris,  egress  of  lens  material  is  prevented  and  the 
inflammatory  reaction  then  takes  on  a  chronic  and  probably  inter- 
mittent character,  and  may  persist  for  a  year  or  more. 

The  microscopic  examination  in  Case  2  shows  that  there  had  been 
an  old  rupture  (traumatic?)  of  the  lens  capsule  and  old  severe  irido- 
cyclitis.  As  a  result  of  the  latter,  the  lens  had  been  walled  off  and 
invaded  by  dense  connective  tissue.  The  lens  cortex  had  become 
completely  cataractous  and  in  many  places  calcified  but  the  nucleus 
had  caused  a  marked  inflammatory  reaction,  as  shown  by  the  fact 
that  it  was  surrounded  by  endothelial  phagocytes  and  giant  cells 
and  deeply  invaded  by  an  abundance  of  pus-cells.  Whether  or  not 
the  original  iridocyclitis  represented  a  reaction  to  lens  matter  it  is, 
of  course,  impossible  to  say,  but  there  can  be  no  doubt  that  the  recent 
reaction  was  of  this  nature.  This  case  seems  to  show  that  reaction 
to  lens  matter  may  recur  at  long  intervals. 


Endophthalmitis  Phacoanaphylactica  277 

From  the  foregoing  observations  it  will  be  seen  that  phacoanaphy- 
lactic  endophthalmitis,  both  clinically  and  histologically,  produces  a 
picture  similar  to,  if  not  identical  with,  that  of  the  so-called  serous 
traumatic  iridocyclitis.  We  are,  however,  not  yet  prepared  to  say 
that  the  latter  condition  is  always  phacoanaphylactic  in  origin. 

After  cataract  extraction  in  hypersensitive  individuals  the  severity 
of  the  reaction  depends  upon  the  amount  of  lens  matter  left  in  the  eye 
and  upon  the  extent  to  which  it  is  protected  by  the  collapsed  capsule. 
In  some  cases  the  reaction  may  subside  while  a  large  amount  of  lens 
substance  still  remains  closed  off  within  the  capsule.  A  discission  of 
the  lens  capsule  will  then  lead  to  a  renewed  inflammatory  reaction. 

It  is  probable  that  the  severity  of  phacoanaphylactic  endophthal- 
mitis also  may  partly  depend  upon  the  degree  of  sensitization  to  lens 
protein.  Our  clinical  data,  however,  are  insufficient  to  establish  this 
as  a  fact,  but  it  is  indicated  by  the  results  of  the  histologic  examina- 
tions, as  noted  above. 

Judging  by  our  skin  tests,  individuals  hypersensitive  to  lens  protein 
are  more  sensitive  to  normal  lens  matter  (immature  cataract)  than 
they  are  to  the  cortex  of  a  fully  mature  cataract,  and  our  histologic 
findings  seem  to  indicate  that  in  hypersensitive  individuals  normal 
lens  matter  is  more  pyogenic  than  is  cataractous  lens  matter. 

Our  tests  made  upon  human  subjects  afford  interesting  confirma- 
tion of  the  facts,  previously  demonstrated  in  other  ways  by  animal 
experimentation,  that  lens  protein  is  not  species  specific,  and  that  an 
individual  may  be  hypersensitive  to  the  protein  of  his  own  lens.  For 
we  found  that  patients  hypersensitive  to  pig  lens  were  also  hyper- 
sensitive to  ox  lens  and  human  lens,  and  that  the  one  individual 
hypersensitive  to  pig  lens  who  was  tested  with  protein  from  her  own 
immature  cataract,  gave  a  positive  reaction  to  the  latter. 

The  sera  of  human  individuals  hypersensitive  to  foreign  proteins 
seldom  give  positive  complement  fixation  or  precipitin  tests.  Miss 
Helen  May,  of  the  Massachusetts  General  Hospital,  has  kindly  made 
these  tests  in  two  of  our  cases  in  which  markedly  positive  intradermal 
reactions  had  previously  been  obtained.  Pig  lens  was  used  as  the 
antigen.  Both  tests  were  negative  in  all  dilutions.  It  would  seem, 
therefore,  that  such  tests  are  of  no  practical  value  in  determining 
hypersensitiveness  to  lens  protein.  Possibly,  however,  they  may 
prove  of  value  in  determining  the  success  or  failure  of  attempts  to 
immunize  hypersensitive  patients. 

In  cases  of  hypermature  cataract  the  fluid  cortex  is  said  to  be 
especially  irritating  to  the  eye.  We  have  had  opportunity  to  examine 


278  F.  H.  VERHOEFF  AND  A.  N.  LEMOINE 

microscopically  two  eyes  with  Morgagnian  cataracts  in  which  there 
had  been  rupture  of  the  lens  capsule  without  history  of  injury.  The 
changes  in  each  eye  differed  only  in  degree.  In  neither  eye  was  the 
nucleus  infiltrated  with  pus-cells.  The  cellular  exudate  which  came 
chiefly  from  the  iris,  consisted  exclusively  of  endothelial  cells,  except 
in  the  more  marked  case  in  which  there  was  an  insignificant  collection 
of  pus-cells  at  one  place  on  the  iris.  The  endothelial  phagocytes 
were  collected  in  abundance  on  the  anterior  surface  of  the  iris  and  on 
the  posterior  surface  of  the  cornea.  The  iris  was  free  from  infiltra- 
tion with  lymphocytes  and  plasma  cells,  and  in  the  more  marked 
case  had  undergone  almost  complete  necrosis.  In  this  case  there 
was  also  hypopyon  of  1.5  mm.  composed  entirely  of  endothelial 
phagocytes,  mixed  with  a  slight  amount  of  blood.  In  the  other  case 
also  there  was  a  slight  amount  of  blood  in  the  anterior  chamber. 
These  findings  are  markedly  different  from  those  in  our  cases  known 
to  be  hypersensitive  to  lens  protein,  as  well  as  from  those  in  our  series 
of  untested  cases  in  which  the  cataract  was  not  hypermature,  and 
strongly  indicate  that  the  irritation  to  the  eye  produced  by  Morgag- 
nian fluid  is  not  a  reaction  of  anaphylaxis  but  is  analogous  to  that 
produced  by  any  necrotic  tissue.1  If  the  patient  should  happen  to  be 
sensitive  to  lens  protein  there  would,  of  course,  be  superimposed  a 
phacoanaphy lactic  reaction. 

The  treatment  of  phacoanaphylactic  endophthalmitis  should  con- 
sist in  the  use  of  atropin  to  dilate  the  pupil  and  of  hot  fomentations 
to  control  the  pain.  If  the  patient  proves  to  be  sensitive  to  atropin, 
hyoscin  may  be  employed  instead.2  If  only  a  small  amount  of 
lens  matter  remains  in  the  eye,  or  the  latter  is  well  protected  by  the 
capsule,  no  other  treatment  may  be  needed.  If  the  condition  does 
not  subside  within  a  reasonable  time,  a  linear  extraction  should  be 
performed  and  the  lens  matter  thoroughly  removed  by  irrigation 
(Case  12).  This  procedure  should  also  be  employed  in  cases  in  which 
the  intraocular  pressure  becomes  greatly  elevated. 

In  cases  which  have  reached  a  chronic  stage  owing  to  the  lens 
matter  having  been  closed  off  by  fibrous  tissue,  the  process  could, 
perhaps,  be  checked  by  desensitizing  the  patient  by  means  of  repeated 

1  Since  this  was  written  one  of  these  patients  has  returned  and  submitted  to  an 
intradermal  test  with  lens  protein.    The  result  of  the  test  was  negative. 

2  It  may  be  well  to  mention  here  that  in  at  least  five  of  our  positive  cases  the 
patient  became  sensitive  to  atropin.     Whether  or  not  this  is  of  any  special  sig- 
nificance in  connection  with  the  fact  that  atropin  is  an  antianaphylactic,  we  are 
at  present  unable  to  say. 


Endophthalmitis  Phacoanaphylactica  279 

injections  of  lens  protein.  Probably,  however,  linear  extraction 
would  be  preferable  in  these  cases  also. 

In  connection  with  prophylaxis,  tests  with  lens  protein  preceding 
operation  would  seem  to  be  of  considerable  value,  especially  in  cases 
of  congenital  and  immature  senile  cataract.  In  cases  of  fully  mature 
senile  cataract,  or  of  sclerosed  lenses,  a  positive  test  would  emphasize 
the  importance  of  removing  all  cortical  matter  possible.  In  cases 
of  congenital  cataract  it  would  indicate  the  employment  of  free  dis- 
cission  followed  by  early  linear  extraction,  or,  possibly,  an  attempt  to 
desensitize  the  patient  to  lens  protein  before  operation. 

In  cases  of  immature  senile  cataracts,  a  positive  test  would  indicate 
the  advisability  of  postponing  operation,  if  possible,  until  the  cata- 
racts had  fully  matured.  When  this  would  entail  too  much  loss  of 
time,  and  the  patient  was  over  fifty  years  of  age,  an  intracapsular 
operation  should  be  performed  upon  one  eye,  and  the  cataract  in  the 
other  allowed  to  become  mature. 

In  the  case  of  a  patient  under  fifty  years  of  age  with  immature 
cataract  it  might  be  well,  owing  to  the  danger  of  rupture  of  the 
capsule,  to  attempt  to  produce  immunity  to  lens  protein  before 
operation.  After  such  immunity  had  been  established,  it  might  be 
possible  in  such  a  case  to  employ  discission  of  the  cataract  followed  by 
simple  linear  extraction.  (Since  this  was  written  we  have  succeeded 
in  desensitizing  such  a  patient,  j  udging  by  the  fact  that  he  now  gives  a 
negative  skin  reaction,  whereas  he  gave  an  intensely  positive  test 
before  treatment  with  lens  protein.  The  details  of  this  case  will  be 
reported  later.) 

SUMMARY  AND  CONCLUSIONS 

In  a  series  of  12  cases  of  rupture  of  the  lens  capsule,  traumatic, 
operative,  or  spontaneous,  in  which  there  occurred  intraocular  in- 
flammation apparently  due  to  lens  matter,  a  positive  skin  reaction 
to  lens  protein  was  obtained  in  every  case. 

Microscopic  examination  of  five  eyes  from  these  cases  showed  a 
characteristic  histologic  picture  in  each. 

In  a  series  of  28  cases  of  rupture  of  the  lens  capsule  in  which  there 
occurred  no  intraocular  inflammation  a  negative  skin  reaction  to  lens 
protein  was  obtained  in  every  case. 

In  a  series  of  50  unselected  cases  of  various  kinds  there  was  a  posi- 
tive skin  reaction  to  lens  protein  in  four  cases. 

An  individual  hypersensitive  to  lens  protein  of  the  ox  or  pig  is  also 
hypersensitive  to  the  protein  of  his  own  lens. 


280  F.  H.  VEBHOEFF  AND  A.  N.  LEMOINE 

Experiments  on  guinea-pigs  seem  to  show  that  free  discission  of 
the  lens  capsule  of  an  animal  sensitized  to  lens  protein  causes  a 
marked  intraocular  reaction  with  characteristic  histologic  changes. 

Inflammation  resulting  from  lens  matter  in  the  eyes  of  individuals 
hypersensitive  to  lens  protein,  we  have  termed  phacoanaphylactic 
endophthalmitis. 

Intraocular  inflammation  resulting  from  rupture  of  a  Morgagnian 
cataract  is  not  usually  phacoanaphylactic  in  nature. 

All  patients  with  congenital  or  immature  cataracts  should  be 
tested  with  lens  protein  before  operation. 

In  the  case  of  a  patient  with  immature  cataracts  in  both  eyes, 
and  over  fifty  years  of  age,  who  is  found  hypersensitive  to  lens  protein, 
the  cataract  in  one  eye  should  be  removed  in  capsule,  or  operation 
postponed  until  it  is  fully  mature.  If  the  patient  is  under  this  age, 
an  attempt  should  be  made  to  desensitize  the  patient  before  operation. 

The  best  treatment  for  severe  phacoanaphylactic  endophthalmitis 
is  removal  of  the  lens  matter  by  operation. 

REFERENCES 

1.  Uhlenhuth:    Zur  Lehre  von  der  Unterscheidung  verschiedener  Eiweissarten 

mit  Hilfe  spezifische  Sera,  Koch  Festschrift,  1903,  49. 

2.  Krauss,  Doerr,  and  Sohma:  Ueber  Anaphylaxie  durch  Organextrakte  (Linsen), 

Wien.  klin.  Wochenschr.,  1908,  xxi,  1084. 

3.  Uhlenhuth  and  Haendel:  Untersuchungen  iiber  die  praktische  Verwertbarkeit 

der  Anaphylaxie  zur  Erkennung  und  Unterscheidung  verschiedener 
Eiweissarten,  Zeitschr.  f.  Immunitatsf.  u.  exper.  Therap.,  1909,  iv,  761; 
also  in  Zeitschr.  f.  Immunitatsforschung,  1910,  iv. 

4.  Andrijew:  Ueber  Anaphylaxie  mit  Eiweiss  tierischer  Linsen,  Arbeiten  aus  dem 

kaiserl.  Gesundh.,  1908,  xxx,  4509;  Krusius:  Zur  biologische  Sonderstellung 
der  Linse,  Zeitschr.  f.  Immunitatsf.  u.  exper.  Therap.,  1910,  v,  699;  Ueber- 
empfindlichkeitsversuch  vom  Auge  aus,  Arch.  f.  Augenh.,  1910,  Ixvii; 
Konigstein:  Zur  Biologie  der  Linse,  Arch.  f.  Augenh.,  1911,  Ixviii,  414; 
Romer  and  Gebb :  Beitrage  zur  Frage  der  Anaphylaxie  durch  Linseneiweiss, 
Arch.  f.  Ophth.,  1912,  Ixxxi,  367;  Hektoen:  The  Specific  Precipitin  Reac- 
tion of  the  Lens,  Amer.  Med.  Assoc.,  1921,  Ixxvii,  No.  1,  32. 

5.  Lagrange  and  Lacoste:    Des  Complications  Subaigues  et  Tardeves  apres 

1'Operation  de  la  Cataracte,  Arch.  d'Ophtal.,  1911,  xxxi,  769. 

6.  Schirmer:  Uber  eine  postoperative  Cyklitis  auf  infectioser  Basis,  C.  R.,  IXe 

Congres  International  Ophtalmologie,  Utrecht,  1899,  402. 

7.  Straub,  M.:  Over  ontstekingen  Van  het  oog  veroorzaakt  Door  Oplossing  Van 

Lensmassa  in  de  ooghlymphe,  Amsterdam,  1919. 

8.  Longcope:   Protein  Hypersensitiveness  and  Its  Importance  in  the  Etiology  of 

Disease,  Jour.  Amer.  Med.  Assoc.,  1921,  Ixxvii,  No.  20,  p.  1535. 

9.  Zinssex:  Studies  on  the  Tuberculin  Reaction  and  on  Specific  Hypersensitiveness 

in  Bacterial  Infection,  Jour.  Exper.  Med.,  1921,  xxxiv,  No.  5,  p.  495. 


Endophthalmitis  Phacoanaphylactica  281 

DISCUSSION 

DR.  LUCIEN  HOWE  (Buffalo,  N.  Y.) :  If  any  of  you  are  interested  in  the 
subject  I  would  ask  you  to  look  at  the  rabbits  which  Prof.  Guyer  has  brought, 
and  I  would  be  glad  to  have  those  who  pass  through  Buffalo,  especially  our 
foreign  friends  who  go  to  Niagara  Falls,  stop  to  see  my  little  menagerie  of 
twenty  or  thirty,  and  learn  from  them  something  additional  of  this  ophthal- 
mic aspect  of  serology. 

The  practical  application  of  what  we  have  heard  seems  to  be  that  it  is  your 
duty  and  mine  to  test  every  cataract  patient  in  the  manner  described  before 
operating. 

Another  point  which  we  too  often  neglect  is  great  thoroughness  in  washing 
out  the  wound — irrigation — in  every  case  whether  there  is  the  least  trace  of 
cortical  substance  visible  or  not. 

PROFESSOR  G.  F.  ROCHAT  (Groningen,  Holland) :  I  would  like  to  ask  first 
about  the  dislocation  of  the  lens.  Perhaps  Dr.  Verhoeff  might  be  able  to  tell 
us  why  the  dislocated  lens  has  such  a  deleterious  effect  on  the  eye.  All  of 
us  know  that  after  the  lens  has  been  thrown  into  the  vitreous  there  is  some 
secondary  inflammation,  and  I  have  never  been  able,  even  with  a  micro- 
scopic section,  to  find  a  definite  reason.  It  may  be  that  in  the  solution  of  the 
lens  material  in  the  vitreous  the  protein  substance  of  the  lens  causes  inflam- 
mation. I  have  made  no  special  experiments  upon  that  subject.  Perhaps 
Dr.  Verhoeff  is  better  informed  than  I  am. 

I  have  noticed  in  a  few  of  his  cases  there  was  trauma — the  capsule  of  the 
lens  was  ruptured.  Might  i.t  be  possible  that  the  removal  of  the  lens — these 
occurred  in  aged  people — gave  rise  to  a  certain  irritation,  and  perhaps  that 
would  be  a  better  explanation  than  the  anaphylactic  explanation  Dr.  Verhoeff 
has  given  us. 

DR.  JAMES  M.  PATTON  (Omaha,  Neb.) :  Our  experience  in  the  use  of  Dr. 
Verhoeff's  method  has  been  limited  to  one  case,  and,  although  the  result  was 
negative,  it  was  scarcely  a  fair  test  as  the  reaction  present  may  have  been 
secondary  to  previous  traumatism.  I  am  reminded  of  three  cases  which 
showed  decided  postoperative  irritation  and  which  might  have  been  foreseen 
had  these  tests  been  used.  These  cases  were  unsuitable  for  ordinary  cataract 
extraction,  due  to  vitreous  degeneration,  and  an  attempt  to  remove  the 
cataracts  by  discission  was  followed  in  each  case  by  marked  irritation.  Later 
on  in  these  cases  at  irregular  intervals  there  were  periods  of  inflammation 
apparently  secondary  to  throwing  out  of  broken-down  lens  substance  in  the 
aqueous. 

It  seems  to  me  that  Dr.  Verhoeff  has  given  us  a  very  valuable  preoperative 
test  that  will  show  us,  in  those  cases  which  are  unsuitable  for  operation, 
whether  we  may  safely  proceed  with  the  discission  operation.  If  this  is  true, 
then  we  can  employ  it  and  be  able  to  give  the  patient  an  idea  as  to  what  the 
outcome  may  be. 

DR.  L.  C.  ROOD  (Boston,  Mass.) :  In  consideration  of  this  excellent  paper 
it  is  striking  to  note  the  freedom  of  the  ciliary  body  from  participation  in  the 
morbid  process  excepting  where  lens  matter  has  access  to  the  vitreous  space, 


282  F.  H.  VERHOEFF  AND  A.  N.  LEMOINE 

and  that  when  the  ciliary  body  is  involved  this  process  is  but  slightly  inter- 
stitial, consisting  mostly  of  plasma  cell  invasion.  Also  that  the  slight  affec- 
tion of  the  choroid,  excepting  in  parts  proximal  or  contiguous  to  the  source 
of  irritation,  contrasts  strongly  with  sympathetic  ophthalmia,  in  which 
condition  the  choroid  is  so  selectively  affected.  Also  that  in  these  cases  of 
endophthalmitis  occurring  after  extraction,  the  endophthalmitis  occurs  after 
those  operations  in  which  masses  of  cortical  matter  and  capsule  remain — a 
big  argument  in  favor  of  intracapsular  extraction.  It  is  also  striking  in 
several  cases  described  in  this  paper  in  which  an  intracapsular  operation  was 
successfully  done  in  the  second  eye,  thus  removing  all  cortical  matter  from 
the  second  eye,  that  the  morbid  process  subsided  in  both  eyes,  because  the 
amount  of  lens  substance  capable  of  absorption  was  lessened  and  therefore 
the  anaphylactic  dosage  lessened.  It  occurs  to  me  that  many  instances  of 
this  type  of  case  (following  trauma  causing  lens  injury  with  consequent 
affection  of  the  second  eye)  must  have  been  clinically  considered  and  diag- 
nosed as  sympathetic  ophthalmia — an  entirely  different  process.  Also  that 
cortical  matter  enclosed  in  capsule  (Case  9)  proved  an  irritant  and  produced 
a  morbid  process  even  as  when  free.  Case  10  shows  strikingly  that  this 
irritation  is  due  to  the  presence  of  cortical  matter,  and  subsides  when  the 
cortex  is  totally  absorbed  or  removed. 

DR.  ARNOLD  KNAPP  (New  York  City) :  I  have  only  one  question,  and  that 
is  why  is  lens  matter  so  well  borne  by  children  and  young  adults? 

DR.  GEORGE  S.  DERBY  (Boston,  Mass.) :  Dr.  Verhoeff  supplied  me  with 
material  to  do  some  of  these  tests,  and  although  my  results  have  been  few  in 
number,  they  were  rather  striking.  So  far  as  I  can  understand  there  is  a 
difficulty  in  keeping  the  lens  protein  material  for  testing  in  a  sterile  condition, 
and  therefore  the  question  arises  of  interpretation  of  the  test,  as  to  whether 
it  is  a  positive  test  from  the  effect  of  the  lens  material  or  whether  it  may  be  a 
slight  infection  in  doing  the  skin  reaction. 

DR.  A.  N.  LEMOINE  (Boston,  Mass.) :  We  wish  to  enumerate  a  few  obser- 
vations made  since  writing  the  paper. 

In  spite  of  every  precaution  it  has  been  found  that  it  is  extremely  difficult 
to  preserve  a  stock  solution  of  lens  protein  without  it  becoming  contaminated, 
consequently  in  our  recent  work  we  have  been  preparing  a  fresh  solution  each 
time  as  it  was  needed.  To  facilitate  this  preparation  the  powder  is  now 
collected  in  the  usual  way,  then  put  up  in  amounts  of  0.003  gram  in  a 
sterile  sealed  ampule.  These  ampules  can  be  made  by  drawing  out  a  three- 
eighth  inch  test  tube  at  its  center,  then  adding  the  weighed  quantity  of  lens 
powder,  and  breaking  and  sealing  the  tube  in  the  drawn  portion.  When  a 
solution  is  desired,  the  top  of  the  tube  is  broken,  and  one  c.c.  of  sterile  saline 
added.  This  makes  a  3.3  per  cent,  solution  of  powdered  lens,  or  a  10  per 
cent,  solution  when  computed  in  terms  of  fresh  lens  protein.  This  method 
of  preparation  does  away  with  the  addition  of  preservatives  which  precipi- 
tate a  portion  of  the  protein  in  the  solution  and  thereby  leaves  a  portion  of 
the  protein  altered. 

Our  subsequent  observations  and  experiments  have  convinced  us  that  there 


Endophthalmitis  Phacoanaphylactica  283 

are  variations  in  degree  of  hypersensitivity  and  sensitization.  Reactions 
which  were  considered  doubtful  in  our  former  observations  are  now  called 
mildly  positive,  since  in  these  cases  when  the  lens  capsule  is  injured  and  there 
is  free  cortical  matter,  the  eye  becomes  quite  irritable  and  convalescence  re- 
tarded, even  though  no  active  iridocyclitis  is  present. 

To  facilitate  the  interpretation  and  recording  of  the  findings  the  following 
terminology  has  been  adopted  for  the  intradermal  test  made  with  a  3.3  per 
cent,  solution  of  powered  lens  protein: 

H — | — H  =  a  reaction  with  an  area  of  erythema  over  six  or  seven  cm.  in 

diameter  with  considerable  elevation  at  the  point  of  injection. 

+  +  =  a  reaction  with  an  erythema  between  three  and  six  cm.  in  diam- 

eter and  a  moderate  elevation  at  the  point  of  injection. 

+  =  a  reaction  with  an  area  of  erythema  about  two  to  three  cm.  in 

diameter  with  a  slight  elevation  at  the  point  of  inoculation. 

=*=  =  a  reaction  with  an  area  of  erythema  less  than  two  cm.  in  diameter 

with  very  little  elevation  at  the  point  of  inoculation. 

when  the  control  and  test  areas  are  practically  the  same. 

Skin  tests  were  made  on  seventy-five  unselected  cases  with  much  the  same 
results  as  obtained  in  our  first  fifty  cases.  Following  is  a  summary:  Below 
30  years  of  age,  18  cases;  30  to  45  years  of  age,  13  cases;  45  to  60  years  of  age, 
19  cases;  over  60  years  of  age,  25  cases.  There  were  forty-three  males  and 
thirty-two  females.  Of  this  number  there  were  seven  cases  which  gave  a  posi- 
tive intradermal  test  to  lens  protein.  Two  were  males  and  five  were  females. 
The  ages  were  fifty,  fifty-five,  sixty-eight,  seventy,  seventy-two  and  seventy- 
six.  There  were  also  six  other  cases  which  gave  a  mildly  positive  (=*=) 
intradermal  test.  Four  were  males  and  two  were  females.  The  ages  of  the 
latter  cases  range  from  thirty-two  to  seventy-two  years.  From  these  figures 
as  well  as  those  given  in  the  paper,  it  seems  that  the  hypersensitiveness 
occurs  only  in  the  later  decades  of  life. 

Our  subsequent  animal  experimentation  seems  to  verify  our  previous 
findings,  except  that  we  have  not  been  able  to  reproduce  experiment  No.  5. 

DR.  F.  H.  VERHOEFF  (closing):  I  wish  to  emphasize  the  fact  that  our 
conclusions  are  based  solely  on  our  observations  in  human  cases.  While  our 
animal  experiments  seem  conclusive  also,  we  find  it  is  impossible  to  rule  out 
entirely  the  possibility  of  slight  infection  playing  some  part  in  the  reaction  in 
animals. 

In  regard  to  inflammatory  reaction,  our  observation  has  been  that  unless 
the  test  is  definitely  positive,  injury  to  the  lens  will  not  cause  inflammatory 
reaction  of  a  serious  nature. 

The  lens  substance  consists  of  three  proteins.  We  employed  the  whole 
lens  substance,  but  it  may  prove  of  value  to  separate  these  proteins  and  as- 
certain whether  there  are  immunologic  differences  between  them. 

In  answer  to  Prof.  Rochat  as  to  dislocation  of  the  lens,  we  have  not  had 
a  case  of  that  kind  to  test.  There  is  a  great  variability  in  these  cases  as  to 
the  amount  of  reaction.  Sometimes  it  is  very  slight,  sometimes  a  good  deal. 
In  the  few  we  have  examined  microscopically  the  dislocated  lens  has  caused 


284  A.  EDWARD  DAVIS 

pigmentary  changes,  at  the  ora  serrata  below,  as  in  the  case  of  foreign 
bodies,  and  I  suppose  it  is  the  repeated  traumatization  over  a  long  period  of 
time  that  causes  these  changes. 

In  answer  to  Dr.  Knapp's  question  about  children,  the  reason  they  do  so 
well  is  because  they  are  not  hypersensitive.  We  have  not  run  across  a  case 
of  congenital  cataract  that  was  hypersensitive. 

In  view  of  Prof.  Guyer's  experiments  it  would  be  well  to  make  the  intrader- 
mal  tests  on  the  parents  of  individuals  who  have  congenital  anomalies  of 
the  eye.  But  there  are  a  good  many  questions  to  be  worked  out  in  this  con- 
nection. 


SERUM  AND  VACCINE  TREATMENT  FOR  THE 
PREVENTION  AND  CURE  OF  CATARACT 

A  PRELIMINARY  REPORT  WITH  THE  RESULTS  OBTAINED  IN  13  CASES 

A.  EDWARD  DAVIS,  A.M.,  M.D. 
New  York  City 

Some  twenty  years  ago  the  author  conceived  the  idea  that  the 
cataractous  lens  in  the  human  eye  might  be  dissolved  or  absorbed  by 
means  of  a  cytolytic  serum;  and  it  is  interesting  to  note  here  some 
experiments  which  were  made  at  the  Pediatrics  Laboratory,  in  West 
54th  Street,  New  York  City,  in  1902  and  1903,  under  the  direction  of 
the  late  Dr.  Justin  DeLisle.  The  sera  used  were:  (1)  Rabbit's  serum 
immunized  against  human  cataractous  lenses.  (2)  Rabbit's  serum 
immunized  against  normal  guinea-pig  lenses. 

EXPERIMENT  1. — March  20, 1902.  Rabbit  No.  1:  Three  guinea-pig  lenses 
freshly  cut  out  and  pulped  up  finely  in  3  c.c.  of  normal  saline  solution 
were  injected  into  a  large  white  rabbit  (peritoneal  injection);  March  31, 
April  14  and  24,  the  same  amount  of  lens  material  was  injected;  on  April  14 
and  24  subcutaneously.  May  1,  bled  the  rabbit  and  secured  63  c.c.  of  clear 
serum.  This  serum  was  hermetically  sealed  in  an  ampule. 

July  18, 1902:  Fresh  serum  was  taken  from  a  rabbit  which  had  not  been 
immunized,  5  c.c.  of  this  fresh  serum  was  added'  to  5  c.c.  of  the  immunized 
serum  of  rabbit  No.  1  in  a  test-tube  into  which  a  freshly  extracted  lens  from 
a  guinea-pig  was  added.  The  tube  was  sealed  with  cotton  and  placed  in  an 
incubator  at  37°  C.  July  20,  lens  partly  absorbed;  July  22,  lens  continues 
to  diminish  in  size;  July  28,  about  one-third  of  the  lens  is  digested  and  the 
fluid  has  turned  a  chocolate  color;  July  31,  lens  remains  about  the  same  size 
and  the  serum  a  little  darker.  All  but  the  nucleus  of  the  lens  has  been  ab- 
sorbed. 

EXPERIMENT  2. — Sept.  23,  1902.    Rabbit  No.  4:  A  medium-sized  female. 


Treatment  for  the  Prevention  and  Cure  of  Cataract  285 

A  crystalline  lens  of  a  guinea-pig  was  placed  under  the  skin  of  rabbit  No.  4 
by  dissecting  up  the  skin  of  the  belly,  inserting  the  lens,  then  sewing  up  the 
skin.  October  3  a  second  guinea-pig  lens  was  inserted  under  the  skin  of  the 
rabbit,  also  on  October  14.  On  October  23  and  November  5  two  crystalline 
guinea-pig  lenses  (each  date)  were  introduced,  and  on  November  15  and  29 
two  guinea-pig  lenses  (each  date)  were  pulped  in  normal  saline  solution  and 
injected  under  the  skin.  December  13  the  rabbit  was  bled  and  about  three 
ounces  of  blood  obtained.  December  24,  ZYi  c.c.  of  the  serum  obtained 
from  this  blood  was  injected  under  the  skin  of  a  large  pregnant  female  guinea- 
pig  (No.  1)  which  had  a  mature  senile  gray  cataract  in  each  eye.  December 
25  guinea-pig  aborted  a  litter  of  pigs;  all  died.  December  29,  little  or  no 
change  in  the  cataractous  lenses  of  the  mother  pig.  December  31,  injected 
3%  c.c.  more  of  the  sensitized  rabbit  (No.  4)  serum  into  the  guinea-pig  (No.  1). 
January  1,  1903,  the  cataracts  are  not  so  gray,  but  of  a  silky  luster,  as  if  water 
was  mixed  among  the  fibers;  January  6,  lenses  pellucid  and  not  so  gray; 
January  6  and  8  (each  date),  2  c.c.  of  serum  from  rabbit  No.  4  was  injected 
into  guinea-pig  No.  1  and  the  cataractous  lens  in  the  guinea-pig  No.  1  con- 
tinued to  clear  slowly. 

In  the  meantime  rabbit  No.  4  was  again  injected  with  guinea-pig  crys- 
talline lenses,  subcutaneous  injections  of  the  pulped  lenses  being  given  on 
December  24,  1902,  January  8,  1903,  and  the  rabbit  was  bled  on  January  20, 
1903,  and  allowed  to  die.  January  25,  1903,  injected  3^  c.c.  of  this  fresh 
serum  from  rabbit  No.  4  subcutaneously  into  guinea-pig  No.  1.  January  30, 
the  cataractous  lens  in  the  left  eye  of  guinea-pig  No.  1  continues  to  clear  and 
the  right  also,  but  not  so  rapidly.  On  February  3  and  11  (each  date)  2%  c.c. 
of  serum  from  rabbit  No.  4  was  injected  subcutaneously  into  guinea-pig  No.  1. 
On  March  6,  1903,  no  further  absorption  of  the  cataractous  lenses  in  the 
guinea-pig  taking  place,  two  minims  of  the  sensitized  serum  from  rabbit  No. 
4  were  injected  into  the  anterior  chamber  of  the  left  eye  of  guinea-pig  No.  1. 
March  7  the  lens  was  swollen  and  the  capsule  ruptured :  slight  redness  of  eye- 
ball. The  entire  cortex  of  this  cataractous  lens  was  absorbed  but  not  the 
nucleus. 

EXPERIMENT  3. — Rabbit  No.  5:  Male,  large  size.  October  14,  1902,  this 
rabbit  was  immunized  to  human  crystalline  lens  by  inserting  human  cata- 
ractous lenses  (whole)  under  the  skin  and  by  pulping  human  cataractous  lenses 
in  normal  saline  solution  and  injecting  same  under  the  skin.  October  14 
and  23,  each  date,  one  human  lens  was  inserted  under  the  skin.  November 
15  and  29,  each  date,  one  human  lens  pulped  and  injected  subcutaneously. 
January  29,  rabbit  was  bled  and  let  die.  Six  drams  of  serum  was  secured, 
which  was  heated  for  one  hour  at  55^°  C.,  then  sealed  in  an  ampule.  Febru- 
ary 17,  1903,  an  untreated  rabbit,  No.  6,  was  bled  for  fresh  serum.  In  a 
sterilized  test-tube  one  human  cataractous  lens  was  placed,  and  to  this  was 
added  2  c.c.  of  fresh  serum  from  rabbit  No.  6,  and  to  this  1  c.c.  sensitized 
serum  from  rabbit  No.  5.  In  a  second  test-tube  1  c.c.  of  fresh  serum  from 


286  A.  EDWARD  DAVIS 

rabbit  No.  6  and  2  c.c.  of  sensitized  serum  from  rabbit  No.  5,  to  which  was 
added  one  human  cataractous  lens.  The  tubes  were  sealed  with  cotton  and 
placed  in  a  sterilizer  at  37°  C.  February  18,  tube  No.  1 :  the  lens  is  softened 
and  partly  absorbed.  Tube  No.  2:  the  lens  is  more  softened  and  there  is 
more  absorption  than  in  the  lens  of  tube  No.  1.  February  25,  tube  No.  1 
continued  absorption  of  the  lens,  about  one-third  being  absorbed.  March 
6,  slight  further  absorption  of  lens  in  each  tube.  On  account  of  evaporation 
of  the  fluid,  5  c.c.  of  serum  from  rabbit  No.  6  (freshly  taken)  was  added. 
In  all  the  cortex  of  the  lens  was  absorbed,  but  not  the  nucleus. 

It  will  be  noted  in  the  above  experiments  that  an  attempt  was  made 
to  dissolve  or  absorb  the  guinea-pig  cataractous  lens,  both  in  vitro  and 
in  vivo,  with  anti-lens  serum,  and  that  in  each  instance  only  a  partial 
success  was  obtained.  With  the  human  cataractous  lens  the  attempt 
to  dissolve  the  lens  was  made  only  in  vitro,  as  I  must  admit  I  did  not 
have  the  courage  to  try  the  experiment  at  that  time  on  the  living 
subject.  The  above  are  a  few  experiments  conducted  at  that  time 
(1902-3),  crude,  it  must  be  admitted,  and  only  partially  successful. 

Because  of  inadequate  laboratory  facilities  and  equipment,  and 
without  any  encouragement  whatsoever  to  continue  these  experi- 
ments, so  very  little  being  known  about  the  subject  at  the  time,  re- 
luctantly the  work  was  given  up  for  a  short  time,  as  I  supposed, 
though  the  idea  continually  lay  in  the  back  of  my  mind.  It  was  not 
until  seventeen  or  eighteen  years  later,  when  the  articles  of  Guyer  and 
Smith  on  "Studies  on  Cytolysins"  l  were  published,  that  my  enthu- 
siasm was  again  stimulated  into  action.  These  investigators  suc- 
ceeded in  liquefying  the  lenses  of  the  young  in  utero  of  rabbits  and  mice 
by  injecting  anti-lens  serum  into  the  mothers,  and,  what  is  more,  suc- 
ceeded in  transmitting  the  eye  defects  so  produced  into  succeeding 
generations — the  special  object,  by  the  way,  of  their  experiments.  It 
is  true  that  they  did  not  succeed,  in  any  instance,  in  liquefying,  ab- 
sorbing, dissolving,  or  affecting  in  any  way  apparently  the  lenses  of  the 
adult  rabbits  or  mice  they  experimented  upon.  However,  later  on  in 
this  paper  more  will  be  said  on  this  point. 

Perhaps  before  giving  the  actual  experiments  conducted  on  the 
human  subjects  it  would  be  well  to  consider  briefly  the  agents — 
cytolytic  sera  and  vaccines — with  which  the  experiments  were  made. 
In  my  earliest  experiments — 1902-03 — of  necessity  I  was  compelled 
to  make  my  own  sera;  in  fact,  to  make  the  bleeding  tubes,  ampules, 
etc.,  by  which  the  serum  was  obtained.  In  the  present  experiments 

1  The  Journal  of  Experimental  Zoology,  May,  1918,  to  August,  1920. 


Treatment  for  the  Prevention  and  Cure  of  Cataract  287 

Dr.  Russell  L.  Cecil  has  assisted  me  in  the  preparation  of  all  the 
sera  and  vaccines,  and  I  am  further  indebted  to  Dr.  Cecil  for 
many  valuable  suggestions  during  the  course  of  these  experiments. 
The  method  of  preparing  the  sera  and  vaccines  is  given  elsewhere  in 
this  paper. 

CYTOLYSINS 

Cytolytic  sera  are  produced  by  injecting  tissue  cells  (antigen)  of  one 
species,  e.  g.,  red  blood-cells,  nerve  tissue,  crystalline  lens,  etc.,  into  the 
blood  of  another  species.  A  lytic  substance  (amboceptor  or  antibody) 
is  thus  formed  which  is  called  a  hemolysin  when  red  blood-cells  are 
used,  a  cy  to  toxin  or  cytolysin  when  other  tissue  cells  are  used  as  the 
antigen.  These  lytic  substances  (cytolysins)  thus  formed  are  specific 
in  the  main  for  the  antigen  (cells)  used  to  produce  the  cytolysin.  Most 
of  the  cytolysins  are  species  specific;  that  is,  they  react  only  on  the 
species  from  which  the  tissue  or  antigen  is  obtained.  A  few  of  the 
cytolysins  are  organ  specific  to  a  greater  or  lesser  degree,  e.  g.,  sperma- 
tozoa, the  testicle,  the  ovary,  and  of  the  tissues  of  the  eye,  the  crystal- 
line lens  and  the  uveal  pigment.  Very  recently  Hektoen1  has  called 
attention  to  the  specific  precipitin  reaction  of  the  lens,  and  cites 
Uhlenhuth,  who  first  called  attention  to  the  fact  that  the  lens  of  dif- 
ferent species  give  the  same  immune  reactions,  that  is,  that  it  is 
organ  specific  and  not  species  specific.  Hektoen  (loc.  cit.},  after  nu- 
merous experiments  with  lens  antigens  of  different  animals,  arrived  at 
the  conclusion  that  the  organ  specificness  of  the  lens  holds  good 
throughout  and  that  the  lens  does  not  appear  to  contain  any  species 
specific  antigens;  hence  the  lens  protein  may  be  regarded  as  chemi- 
cally distinct  and  as  identical  in  diverse  species.  Hektoen  also  claims 
that,  "So  far  the  lens  is  the  only  clean-cut  example  we  have  of  this 
organ  specificness  as  contrasted  with  species  specificness  in  antigen- 
antibody  reactions."  Bearing  directly  on  this  point  Zinsser  has  this 
to  say:  "Recent  critical  study  of  these  organ-cytotoxins  (cytolysins) 
has  revealed,  however,  that  the  specificity  of  a  serum  produced  with 
the  tissues  of  one  organ  is  not  strictly  limited  to  this  organ  alone,  and 
that  the  serum  may  injure  other  organs  as  well." 

Guyer  and  Smith  (loc.  cit.)  also  call  attention  to  the  fact  that  all 
cytolytic  sera  so  far  studied  have  been  found  to  be  more  or  less 
hemolytic  in  action.  Like  the  hemolysins,  they  are  also  specific  in 
action  on  the  special  tissue  used  as  the  antigen  in  the  sensitizing 

1  Hektoen:  Jour.  Amer.  Med.  Assoc.,  July  2,  xxi,  32;  also  Amer.  Jour.  Oph., 
December  21,  xxi,  909. 


288  A.  EDWARD  DAVIS 

process.  However,  they  are  not  absolutely  specific  in  action,  as 
homologous  tissues  may  be  affected  to  a  slight  extent,  e.  g.,  the  vitreous 
when  lens  cells  are  used  as  antigen.  According  to  Ehrlich  and  his 
school,  lack  of  absolute  specificity  is  due  to  the  fact  that  homologous 
tissues  may  have  common  receptors.  It  is  interesting  to  note  in  this 
connection  a  statement  of  Hektoen's:  "The  aqueous  and  vitreous 
humors  appear  frequently  to  contain  lens  substance,  because  in  most 
instances  these  fluids  in  low  dilutions  or  full  strength  react  with  lens 
antiserum,  but  says  nothing  about  the  aqueous.  These  humors  may 
react  with  serum  antiserum  also — not  always — and  then  the  law  of 
species  specificness  obtains.  It  is  true,  of  course,  that  in  some  of  my 
specimens  lens  substance  may  have  become  mixed  with  either  humor 
as  a  result  of  the  handling  incidental  to  the  withdrawal  of  the  humor, 
but  I  believe  in  most  instances  this  did  not  occur,  as  the  withdrawal 
was  made  with  special  care  to  avoid  undue  pressure."  Incidentally  it 
may  be  stated  here  that  the  other  tissues  of  the  eye  of  organ  specificity 
is  the  uveal  pigmejit.  As  is  well  known,  Elschnig1  based  his  theory  of 
sympathetic  ophthalmia  on  the  anaphylactic  action  of  this  pigment, 
and  later  Alan  C.  Woods,2  of  Baltimore,  has  added  to  the  knowledge 
on  this  subject  by  his  studies  and  experiments  at  Johns  Hopkins 
Hospital,  Department  of  Ophthalmology. 

Bearing  in  mind  all  the  limitations  of  specificity  of  action  of  the 
different  cytolytic  sera  so  far  developed,  and  the  dangers  that  may  be 
incurred  by  their  lytic  action  on  the  cells  of  the  homologous  tissues 
other  than  the  tissue  cells  furnishing  the  antigen,  the  experiments  on 
the  human  subject  (related  in  detail  below)  were  proceeded  with  on 
the  basis  that  the  main  action  would  be  on  the  tissue  cells  used  as 
antigen,  especially  on  organ  specific  antigens. 

There  is  one  other  danger  also  which  I  would  point  out  here,  and 
that  is  anaphylactic  shock,  more  or  less  severe  in  character,  which  at 
times  follows  the  intravenous  injection  of  the  lens  antiserum  and  lens 
vaccines.  More  will  be  said  about  this  later. 

Elschnig,  A.:  Studien  zur  sympathischen  Ophthalmie:  I.  Wirkung  von 
Antigen  vom  Augeninnern  aus,  Arch.  f.  Oph.,  1910,  Ixxv,  459;  II.  Die  antigene 
Wirkung  des  Augeninnern  aus,  ibid.,  1910,  Ixxv,  459;  III.  ibid.,  1911,  Ixxviii,  549; 
Elschnig,  A.,  and  Salus,  R. :  IV.  Wirkung  des  Augenpigments,  Arch.  f.  Oph., 
1911,  Ixxix,  428. 

2  Woods,  A.  C. :  The  Anaphylactic  Basis  of  Sympathetic  Ophthalmia,  Tr.  Sect. 
Oph.,  A.  M.  A.,  1917,  133-161;  Woods,  A.  C.:  Ocular  Anaphylaxis.  V:  Experi- 
mental Iridocyclitis,  Arch.  Oph.  (March),  1918,  xlvii,  161.  Woods,  A.  C. :  Im- 
mune Reactions  Following  Injuries  to  the  Uveal  Tract. 


Treatment  for  the  Prevention  and  Cure  of  Cataract  289 

EXPERIMENTS  WITH  CRYSTALLINE  LENS 

CHEMICAL  COMPOSITION  OF  THE  CRYSTALLINE  LENS. — The  greater 
part  of  the  solids  of  the  crystalline  lens  consists  of  proteins.  The  actual 
percentage  of  the  various  solids  in  beef-lens  is  as  follows : 

Protein 35.00 

Fat  and  lipin 0.75 

Salts 0.75 

Water 63.5 

The  protein  constituents  have  been  divided  by  Morner  into  two 
parts — the  albumoids  and  the  crystallins.  Albumoid  is  found  in  the 
lens  fibers  and  is  insoluble  in  water  and  in  salt  solution.  It  dissolves 
readily  in  dilute  acids  or  alkalis.  The  crystallins  (a-  and  /3-crystallin) 
are  globulins,  and  are  soluble  in  water  and  in  salt  solution. 

Jess  has  shown  that  in  the  senile  cataract  of  oxen  the  crystallins  are 
transformed  in  part  to  albumoid.  According  to  Hammarsten,  the 
relation  between  albumoid  and  crystallins  is  changed  with  increasing 
age,  the  albumoid  increasing,  the  crystallins  decreasing.  In  normal  lens 
the  reaction  of  the  crystallins  to  the  albumoid  changes  correspond- 
ingly from  82:  18  in  youth,  to  41 :  59  in  old  age;  in  senile  cataract  the 
relation  can  be  changed  to  25 :  75.  The  other  constituents  of  the  lens 
remain  unchanged. 

PRESENT  EXPERIMENTS. — The  first  experiments  were  concerned 
with  the  effect  of  intravenous  injections  of  anti-lens  serum  on  patients 
suffering  with  cataract.  The  anti-lens  serum  was  prepared  in  three 
different  ways: 

1.  By  immunizing  rabbits  against  normal  guinea-pig  lenses  (anti- 
guinea-pig-lens  rabbit  serum). 

2.  By  immunizing  rabbits  against  human  cataract  lenses  (anti- 
human-cataract-lens  rabbit  serum). 

3.  By  immunizing  a  sheep  against  normal  beef  lenses  (anti-beef- 
lens  sheep  serum). 

In  view  of  the  great  similarity  in  chemical  composition  of  cataract 
lens  to  normal  lens,  there  seemed  to  be  no  reason  for  confining  the 
study  to  the  effect  of  anti-cataract-'ens  serum.  The  comparative 
scarcity  of  cataracts  would  have  made  such  a  study  impracticable; 
hence  the  use  of  sera  from  animals  immunized  with  normal  guinea-pig 
or  beef  lenses. 

Later  on  the  unpleasant  effects  of  the  serum  led  to  a  study  of  the 
effects  of  lens  antigen  when  injected  directly  into  patients  with  cata- 
racts. This  also  appeared  more  rational  on  theoretic  grounds,  as  more 
19 


290  A.  EDWARD  DAVIS 

lens  antibody  was  probably  made  available  by  active  immunization 
than  by  attempts  to  confer  a  passive  immunity  with  serum. 

PROTOCOLS 

1.  PREPARATION  OF  ANTI-GUINEA-PIG-LENS  RABBIT  SERUM. — Fresh  guinea- 
pig  lenses  were  removed  under  sterile  precautions,  ground  into  a  mortar,  and 
suspended  in  normal  salt  solution  in  the  proportion  of  one  lens  to  each  cubic 
centimeter  of  salt  solution.     The  suspension  was  then  centrifuged  to  remove 
coarse  particles,  and  the  supernatant  opalescent  fluid  preserved  in  vaccine 
bottles.     To  insure  sterility,  a  few  drops  of  chloroform  were  added  to  each 
bottle  and  the  preparation  stored  in  the  refrigerator. 

Two  large  rabbits  were  injected  intravenously  every  day  for  six  days  with 
small  doses  of  guinea-pig  lens  extract  as  follows: 

Rabbit  56:  Male,  2511  gm.  Received  0.5  c.c.  lens  extract  intravenously 
on  January  10  and  11,  then  1  c.c.  of  lens  extract  intravenously  every  day 
from  January  12  to  January  15  inclusive. 

Rabbit  57:  Male,  2825  gm.  Received  lens  extract  intravenously  every 
day  for  six  days ;  dosage  same  as  for  rabbit  56. 

January  25,  ten  days  after  last  injection,  rabbits  56  and  57  killed  by  bleed- 
ing from  carotid  arteries. 

Serum  preserved. 

2.  PREPARATION  OP  ANTI-HUMAN-CATARACT-LENS  RABBIT  SERUM. — Human 
cataract  lenses  which  had  been  recently  removed  at  operation  were  dried  over 
anhydrous  calcium  chlorid,  then  ground  to  a  powder  in  a  sterile  mortar.   The 
powder  was  then  suspended  in  normal  salt  solution  in  the  proportion  of  one 
lens  to  2  c.c.  of  saline,  the  coarser  particles  removed  by  centrifuge,  and  the 
supernatant  fluid  decanted  into  sterile  bottles.     A  few  drops  of  chloroform 
were  added  for  preservative. 

Two  large  rabbits  were  injected  intraperitoneally  once  a  week  for  six  weeks 
with  5  c.c.  of  the  lens  extract  as  follows: 

Rabbit  52:  1477  gm.  Received  5  c.c.  of  cataract-lens  extract  intraperito- 
neally December  14,  1921,  and  5  c.c.  every  week  thereafter  until  January  17, 
1922. 

Rabbit  53:  1620  gm.  Received  5  c.c.  of  cataract-lens  extract  intraperito- 
neally December  14,  1921,  and  5  c.c.  every  week  thereafter  until  January  17, 
1922.  January  24  both  rabbits  were  bled  to  death  and  their  serum  preserved 
on  ice. 

Two  other  rabbits  were  injected  with  cataract-lens  extract  intravenously. 
The  injections  were  given  daily  for  seven  days.  Dosage:  0.5  to  1  c.c.  of 
extract. 

Rabbit  58:  1878gm.  Received  0.5  c.c.  cataract-lens  extract  intravenously 
on  February  7  and  February  8.  February  9-13,  the  daily  dose  was  increased 
to  1  c.c.  of  extract. 


Treatment  for  the  Prevention  and  Cure  of  Cataract  291 

Rabbit  59:  1952  gm.  Received  0.5  c.c.  cataract  lens  extract  intraven- 
ously on  February  7  and  February  8.  February  9-13,  the  daily  dose  was 
increased  to  1  c.c.  of  extract. 

February  23,  rabbits  58  and  59  bled  to  death  and  serum  preserved  on  ice. 

The  following  rabbits  were  also  injected  with  cataract-lens  extract 
intravenously : 

Rabbit  60:  Male,  2261  gm.  Received  cataract-lens  extract  intravenously 
on  seven  successive  days.  Dosage:  March  1  and  March  2,0.5  c.c.  extract; 
March  3-8,  1  c.c.  extract;  March  12,  bled  to  death.  Serum  preserved. 

Rabbit  61:  Female,  2647  gm.  Received  cataract-lens  extract  intra- 
venously on  seven  successive  days  (March  1-8).  After  an  interval  of  one 
week  the  rabbit  received  another  series  of  five  injections  on  successive  days 
(March  15-19). 

Dosage:  March  1-2, 0.5  c.c.  extract;  March  3-8, 1  c.c.  extract;  March  15- 
19,  1  c.c.  extract;  March  26,  bled  to  death.  Serum  preserved  on  ice. 

Rabbit  62:  Male,  2474  gm.  Received  cataract-lens  extract  intravenously 
on  six  successive  days  (March  14-19). 

Dosage:  March  14-15, 0.5  c.c.  extract;  March  16-19, 1  c.c.  extract;  March 
26,  bled,  but  not  killed. 

One  month  later  (April  19)  a  second  series  of  injections  was  started.  This 
time  the  injections  were  given  intravenously  at  four-  to  six-day  intervals. 

Dosage:  1  c.c.  of  extract.  Number  of  injections  in  second  series,  13. 
(April  19,  26,  30;  May  3,  9,  13,  17,  21,  25;  June  2,  6,  10,  16.) 

June  27,  bled  to  death.     Serum  preserved. 

Rabbit  63:  Male,  2052  gm.  Received  cataract-lens  extract  intravenously 
on  six  successive  days  (March  14-19). 

Dosage:  March  14-15,  0.5  c.c.  extract;  March  16-19,  1  c.c.  extract; 
March  26,  bled,  but  not  killed.  One  month  later  (April  19)  a  second  series 
of  injections  was  started.  This  time  the  injections  were  given  intravenously 
at  four-  or  five-day  intervals. 

Dosage:  1  c.c.  of  extract.  Number  of  injections  in  second  series,  12. 
(April  19,  26,  30;  May  3,  9,  13,  17,  21,  25;  June  2,  6,  10,  16.) 

June  27,  bled  to  death.    Serum  preserved. 

Rabbit  64:  Female,  2070  gm.  Received  cataract-lens  extract  intra- 
venously on  four  successive  days  (April  5-8) . 

Dosage:  April  5-6,  0.5  c.c.  extract;  April  7-8,  1  c.c.  extract. 

Second  series  of  injections,  also  intravenous,  on  four  successive  days. 

Dosage:  April  12-15,  1  c.c.  extract;  April  20,  bled,  but  not  killed. 

Third  series  of  intravenous  injections  at  four-  to  six-day  intervals. 

Dosage:  1  c.c.  of  extract.  Number  of  injections,  6.  (April  26,  30;  May 
3,  9,  13, 17.)  May  20,  rabbit  bled  and  serum  preserved. 


292  A.  EDWARD  DAVIS 

Rabbit  65:  Male,  1915  gin.  Received  cataract-lens  extract  intravenously 
on  four  successive  days  (April  5-8). 

Dosage:  April  5-6,  0.5  c.c.  extract;  April  7-8,  1  c.c.  extract. 

Second  series  of  injections,  also  intravenous,  on  four  successive  days. 

Dosage:  April  12-15,  1  c.c.  extract;  April  20,  bled,  but  not  killed. 

Third  series  of  intravenous  injections,  April  26-May  17 

Dosage:  1  c.c.  of  extract.  Number  of  injections,  6.  (April  26,  30;  May 
3,  9,  13,  17.)  May  20,  rabbit  bled  and  serum  preserved. 

Rabbit  66:  Male,  2308  gm.  Received  cataract-lens  extract  on  seven  suc- 
cessive days.  All  injections  intravenous. 

Dosage:  May  19-20,  0.5  c.c.  extract;  May  21-25,  1  c.c.  extract. 

Second  series  started  June.  Three  intravenous  injections  of  1  c.c.  each 
at  four-day  intervals. 

June  20:  Rabbit  bled  and  serum  preserved  on  ice. 

Rabbit  67:  Female,  2147  gm.  Received  cataract-lens  extract  intra- 
venously on  seven  successive  days. 

Dosage:  May  19-20,  0.5  c.c.  extract;  May  21-25,  1  c.c.  extract. 

Second  series  started  June  2.  Three  intravenous  injections  of  1  c.c.  each 
at  four-day  intervals.  June  20,  rabbit  bled  and  serum  preserved  on  ice. 

Rabbit  68:  Female,  2476  gm.  Received  cataract-lens  extract  intra- 
venously on  seven  successive  days. 

Dosage:  May  19-20,  0.5  c.c.  extract;  May  21-25,  1  c.c.  extract. 

Second  series  started  June  2,  consisted  of  three  intravenous  injections  of 
1  c.c.  each  at  four-day  intervals. 

June  20:  Rabbit  bled  and  serum  preserved  on  ice. 

Rabbit  69:  Female,  1931  gm.  Received  cataract-lens  extract  intravenously 
on  seven  successive  days. 

Dosage:  May  19-20,  0.5  c.c.  extract;  May  21-25,  1  c.c.  extract. 

Second  series  started  June  2,  consisted  of  three  intravenous  injections  of 
1  c.c.  each  at  four-day  intervals. 

June  20,  rabbit  bled  and  serum  preserved  on  ice. 

3.  PREPARATION  OF  ANTI-BEEF-LENS  SHEEP  SERUM. — Fresh  beef  lenses 
were  removed  under  sterile  precautions  and  dried  in  a  vacuum  oven  at  35°  C. 
The  dried  lenses  were  then  pulverized  in  a  sterile  mortar  and  the  powder  pre- 
served in  sterile  glass  bottle. 

The  lens  extract  was  prepared  as  follows: 

Powdered  lens 10.0    gm. 

Sodium  carbonate 0.5    gm. 

Sodium  chlorid 0.85  gm. 

Distilled  sterile  water 100.0    c.c. 

The  solution  was  centrifuged  to  remove  coarse  particles,  and  the  opalescent 
extract  preserved  by  the  addition  of  a  few  drops  of  chloroform. 

A  sheep  was  injected  intravenously  every  four  to  seven  days  with  the  beef- 


Treatment  for  the  Prevention  and  Cure  of  Cataract 


293 


lens  extract.  From  time  to  time  the  sheep  was  bled  and  the  serum  preserved 
for  further  study  and  for  therapeutic  inoculations. 

Sheep  protocol  follows: 

Sheep  No.  1:  Female,  full  grown,  received  beef-lens  extract  intravenously: 
on  September  21,  23,  2  c.c.;  September  27,  3  c.c.;  and  on  October  3,  7,  and 
13,  4  c.c.  each  day.  Followed  immediately  by  symptoms  of  anaphylaxis. 
On  October  19  received  2  c.c.  extract  intravenously.  No  symptoms;  Oc- 
tober 25,  bled  from  jugular  vein.  Serum  preserved.  On  October  27,  3  c.c. 
extract  intravenously;  November  4,  2  c.c.;  November  10,  1  c.c.;  November 
16,  2  c.c.;  November  21,  2  c.c.  On  December  4,  350  c.c.  blood  removed 
from  jugular  vein.  Serum  preserved;  December  7,  4  c.c.  extract  sub- 
cutaneously. 

PROTOCOLS  OF  PRECIPITIN  TESTS 

1.  PRECIPITINS  IN  RABBIT  SERUM  FOR  CATARACT-LENS  PROTEIN. — The. 
serum  from  rabbit  65  was  tested  for  precipitins  against  cataract  lens  after 
having  received  12  intravenous  injections  of  human  cataract-lens  extract. 

The  tests  were  performed  as  follows : 

Various  dilutions  of  lens  extract  (10%  solids)  were  made  with  normal  salt 
solution,  and  this  served  as  the  antigen. 

The  rabbit  serum  was  diluted  in  the  usual  way  (1 : 10,  1 : 100,  1 : 1000,  etc.). 

Equal  parts  of  extract  and  diluted  serum  (0.5  c.c.  each)  were  mixed  and 
incubated  for  two  hours  at  37°  C. 

The  results  follow: 


Immune  rabbit  serum  — 

1:10 

1:100 

1  :  1000 

1  :  10,000 

1  :  100,000 

Saline 

Cataract-lens    anti- 
gen.   .  .        .             1  :  10 

+  -f 

+  4- 

+ 

1:100 
1  :  1000 

+ 
+ 

+ 

- 

- 

REPORT  OF  CASES. — All  of  these  patients  were  inmates  of  the  State 
Hospital  for  the  Insane,  Central  Islip,  N.  Y.  All  injections  of  serum 
and  vaccine  were  administered  intravenously,  except  when  otherwise 
stated. 

CASE  1. — Elizabeth  S.,  admitted  to  the  hospital  May  21,  1920,  aged 
eighty-three;  nativity  Germany;  white,  housework,  widowed.  Physical 
symptom  complex:  general  arteriosclerosis,  enlargement  of  the  heart,  im- 
pairment of  the  hearing;  mature  senile  gray  cataract  right  eye;  projection 
good,  pupils  active,  anterior  chamber  normal  in  depth,  tension  normal  each. 
This  patient  was  the  first  to  receive  anti-human-lens  rabbit  serum.  The 
serum  was  administered  intravenously  on  the  following  dates:  February  1, 


294  A.  EDWARD  DAVIS 

21,  3  c.c.,  from  rabbit  No.  52;  February  6,  11,  15,  5  c.c.,  from  rabbit  No. 
52;  February  20,  24,  5  c.c.,  from  rabbit  No.  53;  March  3,  7,  13,  20,  23,  5  c.c., 
from  rabbit  No.  59;  March  28,  5  c.c.,  from  rabbit  No.  60;  April  1,  7,  13,  5 
c.c.,  from  rabbit  No.  61;  April  18,  5  c.c.,  from  rabbit  No.  61. 

The  patient  vomited  five  minutes  after  the  injection.  April  22 :  Examina- 
tion of  the  eye  shows  wedge-shaped  sectors  of  translucency  forming  in  the 
upper  half  of  the  lens,  the  edge  of  the  wedge  being  at  the  center  of  the 
lens.  April  22:  5  c.c.  from  rabbit  No.  61;  April  28,  5  c.c.  (mixed)  from 
rabbits  Nos.  62  and  65.  Patient  vomited  five  minutes  following  injection, 
but  showed  no  other  ill  effects.  Patient  put  to  bed  on  account  of  general 
weakness.  May  6,  5  c.c.  (mixed)  from  rabbits  Nos.  62  and  65.  May  9: 
Patient  had  an  attack  of  syncope  due  to  general  arteriosclerosis.  She  became 
weak  on  her  way  to  the  dining-room  and  had  to  be  returned  to  bed.  May  11 : 
4  c.c.  (mixed)  from  rabbits  62  and  65,  no  reaction  followed.  May  16:  5  c.c. 
(mixed)  from  rabbits  62  and  65;  patient  showed  slight  reaction  at  the  time 
but  did  not  vomit  as  on  the  two  former  occasions  when  she  had  reactions. 
Later  in  the  day  the  patient  died  from  a  stroke  of  apoplexy.  At  the  time  of 
the  death  of  this  patient  the  upper  half  of  the  lens  was  semitranslucent 
(pellucid  in  appearance),  the  outer  cortical  layers  apparently  had  become 
liquefied.  Unfortunately,  no  postmortem  was  allowed,  and  the  eye  could 
not  be  obtained  for  examination  under  section.  Because  of  the  advanced 
age,  the  pronounced  arteriosclerosis,  and  enlargement  of  the  heart,  this 
patient  was  an  unfavorable  subject  for  the  treatment,  and  we  have  not  given 
the  injections  to  any  but  the  physically  sound  (except  moderately  arterio- 
sclerotic  subjects)  since.  We  do  not  attribute  the  fatal  attack  to  the  treat- 
ment, as  on  May  9,  three  days  after  any  injections  had  been  given,  the 
patient  had  an  attack  of  syncope,  and  all  but  passed  away. 

It  would  have  been  highly  interesting  and  most  instructive  to  have  made 
sections  of  the  crystalline  lens  and  found  out  what  physical  changes  had 
taken  place  in  its  structure. 

CASE  2. — Susan  A.,  admitted  July  2,  1921,  aged  about  sixty  years,  Ameri- 
can, housewife,  good  physical  condition.  Mature  senile  gray  cataract,  left 
eye;  projection  good,  anterior  chamber  normal  in  depth  left,  slightly  shallow 
in  right;  tension  normal  each,  pupils  active.  Serum  was  administered  intra- 
venously on  the  following  dates:  July  10,  15,  20,  3  c.c.  from  rabbit  No.  66. 
On  July  20,  within  two  minutes  after  the  injection,  the  patient  complained  of 
nausea,  excruciating  intermittent  pain  low  down  in  the  lumbar  region.  The 
head  and  neck  became  congested  and,  a  little  later,  a  marked  lividity  followed. 
She  experienced  no  difficulty  in  breathing  and  the  pulse  was  regular  and  of 
good  quality.  After  seven  minutes,  all  symptoms  of  distress  subsided  and 
patient  was  allowed  to  sit  up.  Because  of  this  marked  reaction  to  the 
serum-lens  vaccines  were  substituted  in  place  of  serum  injections  (beef-lens 
10%  in  solution  with  sodium  carbonate  0.5%,  sodium  chlorid  0.9%,  and 
chloroform  q.  s.  to  preserve).  July  26, 31,  August  2,  1  c.c.  beef-lens  vaccine. 


Treatment  for  the  Prevention  and  Cure  of  Cataract  295 

August  5,  10,  15,  20,  25,  31,  2  c.c.  beef-lens  vaccine.  September  10,  2  c.c. 
beef-lens  vaccine.  Examination  of  the  left  eye  shows  wedges  (prism-shaped 
sectors)  of  translucency  in  nasal  and  temporal  halves,  horizontal  meridian, 
of  the  left  lens,  the  bases  of  the  wedges  are  about  1  mm.  in  width  and  come 
to  a  point  at  the  center  of  the  lens,  cortical  layers  alone  being  affected.  In- 
cipient cataract  in  right  eye  unchanged  by  the  treatment.  September  15, 
1  c.c.  beef-lens  vaccine  was  given  intradermally  for  sensitization,  a  pro- 
nounced redness  and  irritation  of  the  skin  was  produced  at  the  site  of  the 
injection.  September  20,  21,  2  c.c.  beef-lens  vaccine;  September  25,  30, 
October  5,  3  c.c.;  October  10,  15,  3%  c.c.;  October  20,  30,  3  c.c.  The  trans- 
lucent sectors  in  the  lens  continue  to  increase  in  size,  and  a  fresh  sector  has 
appeared  in  the  lower  half.  November  4,  9,  %  c.c.  anti-beef-lens  sheep 
serum.  Following  the  second  injection  there  was  a  marked  general  reaction — • 


Fig.  1. — Case  2.     Mrs.  A.     L.  E.,  two  stages. 

flushing  of  the  skin,  pain  in  the  back,  some  weakness,  moderate  elevation  of 
the  temperature,  and  six  hours  later  fall  in  the  blood  pressure.  Before  treat- 
ment 118-218,  six  hours  later  dropped  to  100-190.  November  14,  treat- 
ment omitted.  Because  of  the  marked  reaction  the  patient  was  again 
placed  on  the  beef-lens  vaccine.  November  16,  J^  c.c.;  November  19,  % 
c.c.;  November  21,  following  last  injection,  patient  complained  of  inter- 
mittent pain  in  the  back  and  a  desire  to  urinate  frequently  for  first  few  hours 
after  the  injections;  temperature  rose  to  100°  and  pulse  to  90.  Today  gave 
1  c.c.  beef-lens  vaccine,  no  pain  or  reaction  of  any  kind  followed.  November 
29,  2  c.c.  beef-lens  vaccine;  blood  pressure  before  injection  100-200,  after, 
110-210.  One  minim  of  the  vaccine  was  given  intradermally,  and  marked 
local  reaction  followed.  November  30,  temperature  100,  no  other  symptoms. 
December  4,  1  c.c.  beef-lens  vaccine;  within  three  minutes  excruciating  pain 
in  the  back,  involuntary  movements  of  bladder  and  bowels,  and  slight  diffuse 


296  A.  EDWARD  DAVIS 

redness  of  the  skin.  One  hour  later  temperature,  100;  pulse,  80;  respira- 
tion, 26.  December  9,  because  of  the  severe  reaction,  it  was  decided  to  stop 
intravenous  injections  and  to  give  the  vaccine  subcutaneously,  beginning 
with  1  c.c.  and  increasing  the  dose  H  c.c.  at  a  time.  December  14,  1  c.c. 
beef-lens  vaccine  subcutaneously;  December  19,  lj^  c.c;  December  24,  2 
c.c.  Immediately  before  injection  B.  P.  180-90,  pulse  90.  Six  hours  later 
B.  P.,  210-90;  pulse,  90.  Differential  blood  count:  No.  cells,  270;  poly., 
56.7;  lym.,  38.5;  1.  mon.,  1.9;  eos.,  2.2;  bas.,  .4;  hem.,  65%. 

No  reactions  so  far  from  the  subcutaneous  injections.  The  lower  half  of 
the  lens  in  the  left  eye  has  a  bluish,  translucent,  wedge-shaped  sector,  having 
coalesced  except  one  fibrous  sector,  which  extends  directly  downward  to  VI 
on  the  clock  dial.  With  the  ophthalmoscope  there  is  a  very  faint  reflex 
through  this  portion  of  the  lens.  The  right  lens  apparently  has  not  been 
affected  one  way  or  the  other,  and  vision  remains  20/40.  (See  Fig.  1.) 

CASE  3. — Catherine  C.,  admitted  August  3, 1921,  aged  about  seventy-seven 
years;  some  arterial  thickening,  impaired  hearing,  cataracts  in  each  eye, 
mature  right,  incipient  left,  of  the  dark  sclerosing  type;  anterior  chambers, 
pupils,  and  tension  normal;  good  light  projection.  August  8,  1  c.c.  serum 
intravenously  from  rabbit  69;  August  15,  2  c.c.  serum  intravenously  from 
rabbit  69.  Complained  of  feeling  slightly  dizzy,  but  showed  no  objective 
symptoms.  Statement  unreliable  owing  to  mental  condition.  August  20, 
2  c.c.  serum  from  rabbit  No.  69.  A  slight  amount  of  this  injection  was  given 
subcutaneously  before  the  needle  entered  the  vein.  On  August  22  there  was 
marked  redness  and  swelling  of  the  forearm  and  hand;  August  24,  still  com- 
plains of  soreness  and  stiffness  of  hand  and  arm,  but  redness  and  swelling 
subsiding.  General  condition  good.  August  25,  gave  1  c.c.  intravenously 
serum  from  rabbit  No.  69.  Two  minutes  later  the  patient  complained  of 
excruciating  pain  across  the  hips,  and  about  four  hours  after  the  treatment  she 
fainted.  During  the  attack  she  vomited  and  the  circulation  was  poor.  Two 
hours  later  still  extremely  irregular  and  slow  pulse,  54  per  minute,  and  com- 
plained of  weakness.  All  treatment  was  suspended  for  about  one  month. 
September  20,  25,  1  c.c.  10%  beef-lens  vaccine;  September  30,  }/%  c.c.  10%; 
October  5,  H  c.c.  10%;  October  10,  15,  1^  c.c.  10%.  Patient  complained 
of  nausea  and  gastro-intestinal  disturbance  after  the  last  injection.  Oc- 
tober 20,  30,  1  c.c.  beef-lens  vaccine.  Examination  of  the  eyes  shows  no  dis- 
tinct changes  in  the  lens  opacities.  November  4,  J4  c.c.  anti-beef-lens  sheep 
serum.  Marked  reaction  within  five  minutes,  tachycardia,  retching,  com- 
plaint of  burning  sensation  throughout  the  body,  anxiety,  dyspnea,  surface 
of  the  body  flushed  at  first,  then  bluish  in  color,  especially  about  the  nose  and 
mouth,  recurrent  vomiting  began  after  the  injection  and  lasted  for  12  hours. 
All  serum  injections  were  discontinued.  November  16,  returned  to  the  10% 
beef-lens  vaccine — Yi  c-c-  being  given.  November  19,  ^  c.c.;  November  24, 
1  c.c.;  November  29,  2  c.c.  Blood  pressure  before  injection  70-130,  after 
injection  80-120.  Two  drops  of  the  vaccine  given  intradermally;  no  local 


Treatment  for  the  Prevention  and  Cure  of  Cataract  297 

reaction  noted.  November  30,  temperature,  98;  pulse,  76;  headache,  sick- 
ness at  the  stomach,  vertigo,  but  no  vomiting.  Because  of  continued  reac- 
tions intravenous  injections  were  discontinued  and  the  vaccines  were  given 
subcutaneously.  December  4,  9,  l/%  c.c.  beef-lens  vaccine;  December  14, 
1  c.c.;  December  19,  1^  c.c.;  December  20  patient  complained  of  nausea 
and  vomited.  Examination  of  the  eye  reveals  practically  no  changes  in  the 
cataracts.  December  24,  2  c.c.  beef-lens  vaccine.  Immediately  before  in- 
jection, blood  pressure,  140-85;  pulse,  84;  six  hours  after  blood  pressure 
124-80;  pulse,  84.  Differential  blood  count:  No.  cells,  250;  poly.,  64.4; 
lym.,  28;  1.  mon.,  4.8;  eos.,  2.4;  bas.,  .4;  hem.,  80%. 

CASE  4.— Mary  S.,  admitted  August  24,  1904,  now  aged  seventy-one  years. 
General  condition  only  fairly  good;  right  femoral  hernia,  varicose  veins  in 
lower  extremities,  impairment  in  hearing  and  sight.  Mature  senile  gray 
cataract  right  eye,  immature  nuclear  cataract  left,  also  choroidal  changes 
noted  in  the  fundus.  Anterior  chamber  normal  depth  right,  slightly  shallow 
left,  pupils  and  tension  normal,  light  projection  good.  August  5,  1  c.c. 
serum  from  rabbit  No.  66;  August  10,  15,  20,  2  c.c.  serum  from  rabbit  No. 
66;  August  21,  twenty-four  hours  after  the  last  injection  the  patient  had  a 
fainting  attack  which  lasted  two  or  three  minutes.  There  was  some  redness 
of  the  forearm  and  hand  following  the  injection.  August  25,  1^  c.c.  serum 
from  rabbit  66;  no  reaction.  August  31,  because  of  the  severe  reactions,  the 
serum  was  discontinued,  and  2  c.c.  beef-lens  vaccine  was  given.  September 
1,  the  patient  was  left  in  bed  after  the  last  treatment  and  seemed  all  right. 
However,  3  hours  later,  when  she  got  up  to  go  into  the  dining  room,  she 
vomited  and  on  the  way  back  to  the  ward  fainted.  September  10,  no  change 
was  noted  in  either  cataract.  September  15,  1  c.c.  beef -lens  vaccine  given; 
one  drop  of  the  vaccine  given  intradermally  showed  marked  focal  reaction. 
September  20,  25,  30,  Oct.  5,  2  c.c.  beef-lens  vaccine;  October  10,  15,  2l/% 
c.c.;  October  20,  30,  3  c.c.  Examination  of  the  eyes  showed  but  little  if 
any  changes  in  the  lenses.  One  speck  of  lime  deposit  was  noted  on  temporal 
side  of  the  right  lens.  November  4,  J^  c.c.  anti-beef-lens  sheep  serum. 
November  9,  %  c.c.  Blood  pressure  before  injection  190-90;  six  hours 
later  194-90.  November  14,  1  c.c.  anti-beef-lens  sheep  serum  was  admin- 
istered slowly;  within  5  minutes,  scarlet  appearance  of  body,  particularly 
the  face,  later  a  bluish  color  of  the  lips,  no  alteration  of  circulation  or  respira- 
tion. Because  of  severe  reaction  no  more  injections  of  serum  were  given. 
No  changes  in  cataracts  noted  on  examination.  November  19,  ^  c.c.  beef- 
lens  vaccine;  November  24,  1  c.c.;  November  29,  2  c.c.  Blood  pressure 
before  the  last  injection  220-110;  after  the  injection  180-130,  at  4  p.  M.  ; 
temperature,  102;  pulse,  98;  at  7  P.  M.,  temperature,  101;  pulse,  90.  No- 
vember 30,  patient  complained  of  not  feeling  well  but  was  up  and  around. ' 
December  4,  %  c.c.  beef-lens  vaccine;  no  immediate  reaction.  One  hour 
later  temperature,  100;  pulse,  80;  respiration,  22;  six  hours  later  tempera- 
ture, 98.6;  pulse,  80.  Because  of  severe  reaction  all  intravenous  injections 


298  A.  EDWARD  DAVIS 

were  discontinued.  December  4,  subcutaneous  injections  of  beef-lens 
vaccines  were  started.  December  9,  Yi  c.c.;  December  14,  1  c.c.;  Decem- 
ber 19,  \]/^  c.c.;  December  24,  2  c.c.  Immediately  before  injection,  blood 
pressure,  170-90;  pulse,  96;  six  hours  after,  blood  pressure,  180-104;  pulse, 
90.  Differential  blood  count:  No.  cells,  212;  poly.,  70.3;  lym.,24.1;  1.  mon., 
3.8;  eos.,  1.4;  bas.,  0.4;  hem.,  78%. 

There  are  practically  no  changes  in  the  cataractous  lenses. 

CASE  5. — Louise  S.,  admitted  1918,  aged  seventy  years,  white,  widowed. 
Physical  condition  fairly  good;  mature,  senile,  gray  cataract  right  eye, 
half  mature  cataract  left  eye;  right  anterior  chamber  normal  in  depth;  pro- 
jection good;  pupils  normal.  December  13,  1918,  successfully,  extracted 
the  cataract  from  right  eye.  September  20,  1921,  the  left  eye  has  nuclear 
cataract  about  two-thirds  mature;  anterior  chamber  somewhat  shallow, 
tension  normal.  The  treatment  in  this  case  was  begun  with  beef-lens  vaccine 
given  intravenously.  September  20,  25,  30,  1  c.c.;  October  5,  1^  c.c.; 
October  15,  2  c.c. ;  October  15,  2j/£  c.c.;  October  20,  3  c.c.;  October  30,  3  c.c. 
November  1,  examination  of  the  eye  shows  no  change  in  the  cataract.  No- 
vember 4  began  intravenous  injections  of  anti-beef-lens  sheep  serum,  ^  c.c. 
given  as  initial  dose.  Marked  reaction  within  5  minutes,  pain  in  the  back, 
shortness  of  breath,  tachycardia,  tremor,  and  chilly  sensation.  Blood 
pressure,  170-100.  Treatment  omitted  until  November  16  when  she  was 
again  placed  on  beef-lens  vaccine.  November  16,  ^  c.c.;  November  19, 
%  c.c.;  November  21,  1  c.c.  No  reaction,  pulse,  90;  temperature,  normal. 
November  29,  1  c.c.  beef-lens  vaccine;  blood  pressure  before  160-80,  after 
injection,  160-100.  One  or  two  drops  of  the  vaccine  given  intradermally 
show' no  local  reaction;  that  is,  there  was  apparent  absence  of  sensitization. 
November  30,  about  24  hours  after  the  last  injection;  temperature,  102.6; 
pulse,  116,  intermittent;  patient  had  a  chill  and  complained  of  general 
weakness  with  stomach  sickness  and  headache,  but  no  vomiting.  Decem- 
ber 4,  ^  c.c.  beef-lens  vaccine;  within  3  minutes  diffuse  redness  of  the  body, 
chill,  severe  pain  in  the  back.  One  hour  after  the  injection,  temperature, 
99.2;  pulse,  86;  respiration,  22.  Six  hours  later  temperature  and  pulse  same. 
Because  of  severe  reactions,  the  vaccines  were  given  subcutaneously.  De- 
cember 9,  J^  c.c.  beef -lens  vaccine;  December  14,  1  c.c.;  December  19,  1^ 
c.c.;  December  24,  2  c.c.  Immediately  before  injection,  blood  pressure, 
170-90;  pulse,  144;  six  hours  after,  blood  pressure,  180-95;  pulse,  120. 
Marked  arhythmia  of  the  pulse;  treatments  stopped  temporarily.  Examina- 
tion of  the  eye  shows  practically  no  change  in  cataract.  Differential  blood 
count:  No.  cells,  250;  poly.,  64.4;  lym.,  32.8;  1.  mon.,  2.4;  eos.,  0.4. 

CASE  6. — Caroline  R.,  admitted  July  11,  1919,  aged  forty-two,  white, 
married.  Physical  condition  good;  varicose  veins,  both  legs;  myopia  with 
diffuse  nuclear  cataracts  each  eye;  the  inner  cortical  layers  involved;  pupils 
normal  in  size  and  reactions;  anterior  chamber  slightly  shallowed  each  eye. 
July  26,  began  intravenous  injections  anti-human-lens  rabbit  serum.  July 


*     Treatment  for  the  Prevention  and  Cure  of  Cataract  299 

26,  1  c.c.  serum  from  rabbit  No.  65.  July  27,  lj/£  c.c.  serum  from  rabbit  No. 
65.  August  5,  10,  15,  20,  25,  31;  September  5,  10,  2  c.c.  serum  from  rabbit 
No.  65.  September  15,  1  c.c.  serum  from  rabbit  No.  65,  one  drop  injected 
intradermally;  local  reaction  followed.  September  20,  2  c.c.  serum  from 
rabbit  No.  65;  September  25,  30;  October  5,  10,  15,2%  c.c.  from  rabbit  No. 
65.  November  1,  examination  of  the  eyes  shows  no  distinct  change  in 
cataracts.  November  4,  intravenous  injections  of  anti-beef-lens  sheep  serum 
begun.  November  4,  ^  c.c.;  November  9,  1  c.c.  Blood  pressure  before 
injection,  118-70;  six  hours  later,  100-70.  November  14,  1%  c.c.  anti- 
beef-lens  sheep  serum.  November  19,  1%  c.c.  November  24,  10  A.  M., 
patient  complained  of  headaches;  pulse,  102;  10.15  A.  M.,  gave  2  c.c.  sheep 
serum,  followed  by  moderate  reaction,  pain  over  the  sacrum  and  down  the 
anterior  parts  of  the  thighs,  lasting  for  a  minute,  moderate  redness  of  the 
body,  no  reduction  pulse  rate;  temperature  normal.  November  29,  2  c.c. 
anti-beef-lens  sheep  serum.  Blood  pressure  before  injection,  100-70;  im- 
mediately after,  100-60.  Two  drops  of  serum  given  intradermally  showed 
moderate  local  reaction.  November  30,  twenty-four  hours  after  the  last 
injection,  temperature,  100.2°;  pulse,  96;  complained  of  pain  in  the  back,  not 
excessive.  December  4,  1%  c.c.  anti-beef-lens  sheep  serum;  no  immediate 
reaction,  but  complains  of  more  or  less  headache  all  the  time.  Six  hours 
later  temperature  100.6°;  pulse,  90;  respiration,  24.  Because  of  the  con- 
tinued reaction  the  injections  were  given  subcutaneously.  December  9, 
1%  c.c.;  December  14,  2  c.c.;  December  19,  2%  c.c.;  December  24,  3  c.c. 
Immediately  before  the  last  injection,  blood  pressure,  100-60;  pulse,  90;  six 
hours  later,  blood  pressure,  118-70;  pulse,  90.  Examination  of  the  eyes 
shows  slight  clearing  of  the  lens  opacities,  especially  of  the  cortical  part  of 
the  lens.  Differential  blood  count:  No.  cells,  220;  poly.,  72.7;  lym.,  20.9; 
1.  mon.,  2.7;  eos.,  3.2;  bas.-,  0.5;  hem.,  68  %. 

CASE  7. — Jacob  L.,  admitted  September  22,  1906.  Now  aged  fifty-six, 
single,  a  middle-sized,  defective  looking  individual;  diminished  knee-reflex 
action,  but  no  other  physical  abnormalities.  On  April  9,  1920,  I  extracted 
mature  senile  gray  cataract  from  right,  securing  20/15  V.  with  plus  10  D. 
spherical  glass  (patient  cooperative).  Vision  left  eye  =  20/15  without 
glass.  February  1,  1921,  there  is  an  incipient  cataract  in  left  eye;  spiculae 
of  opacity  at  the  extreme  periphery  of  the  lens,  which  do  not  interfere  with 
the  vision,  which  is  still  20/15,  as  it  was  a  year  ago.  Anterior  chamber  nor- 
mal in  depth;  pupil  normal  in  size  and  reaction.  February  1,  1921,  intra- 
venous injections  of  anti-human-lens  rabbit  serum  were  begun  (he  being  the 
second  patient  to  receive  the  treatment).  February  1,  6,  3  c.c.  from  rabbit 
No.  52;  February  11,  6  c.c.  serum  from  rabbit  52;  February  15,  20,  25, 
March  2,  7,  5  c.c.  from  rabbit  53;  March  13,  6  c.c.  serum  from  rabbit  59. 
There  were  no  reactions  at  all  from  these  injections,  but  the  patient  steadily 
lost  in  weight.  Examination  of  the  eyes  showed  no  change  whatsoever  in 
the  opacities  in  the  lens  and  vision  remained  20  /1 5.  Because  of  loss  of  weight 


300  A.  EDWARD  DAVIS 

the  injections  were  discontinued  for  two  months,  then  taken  up  again  in  July, 
but  were  again  discontinued  because  of  steady  loss  of  weight.  This  patient 
was  examined  last  on  December  24,  1921,  when  the  opacities  in  the  left  lens 
remained  exactly  as  they  were  at  the  beginning  of  treatment,  and  vision  was 
20/15.  Whether  the  treatment  had  anything  to  do  with  preventing  advance 
in  the  opacities  in  the  lens  of  the  left  eye  is  problematic.  All  we  know  is  the 
opacities  did  not  increase,  though  he  had  a  mature  cataract  develop  in  the 
right  eye  previous  to  the  treatment.  Examination  of  this  patient's  blood  on 
December  24,  1921,  resulted  as  follows:  No.  cells,  214;  poly.,  60.8;  lym., 
33.1;  1.  mon.,  4.7;  eos.,  0.9;  bas.,  1.4;  hem.,  0.78  %. 

CASE  8. — Michael  B.,  admitted  October  18, 1921,  aged  sixty  years.  Italian 
laborer,  tall,  well-developed  man,  some  hardening  of  the  arteries  and  a  moder- 
ate arcus  senilis  each  eye,  incipient  cataract  each  eye,  more  marked  in  right. 
V.  R.  E.,  20/30  +  ;  L.  E.,  20/30.  Patient  was  given  only  intravenous  in- 
jections of  beef-lens  vaccines.  November  4,  1  c.c.;  November  9,  2  c.c.; 
November  14,  3  c.c.;  November  19,  4  c.c.;  November  24,  5  c.c.  Immedi- 
ately following  the  last  injection  the  patient's  entire  body  became  flushed, 
and  he  complained  of  nausea  and  headache.  Later,  temperature  100; 
pulse,  90;  respiration,  22.  November  19,  \%  c.c.  beef-lens  vaccine;  one  or 
two  drops  of  the  vaccine  were  given  intradermally;  no  local  reaction.  De- 
cember 4,  1  c.c.  beef -lens  vaccine;  because  of  reactions,  the  vaccine  from  this 
date  was  given  subcutaneously.  December  9,  1  c.c.;  December  14,  2 c.c.; 
December  19,  3  c.c.;  December  24,  4  c.c.  Immediately  preceding  the  last 
injection  blood  pressure,  130-80;  pulse,  80.  Six  hours  later  blood  pressure, 
138-92;  pulse,  92.  December  24  examination  of  eyes  shows  no  change  in 
the  lenses,  vision  remains  as  at  beginning  of  treatment,  six  weeks  ago.  Dif- 
ferential blood  count:  No.  cells,  246;  poly.,  57;  lym.,  29.7;  1.  mon.,  10.9; 
eos.,  2;  bas.,  4;  hem.,  59%. 

CASE  9. — Bernadino  C.,  admitted  August  9,  1921,  aged  sixty-nine  years. 
Italian,  male,  white.  Physically  undersized,  well-preserved  old  man,  showing 
moderate  general  arteriosclerosis,  chronic  valvular  endocarditis.  Pupils 
normal  in  size  but  somewhat  sluggish  in  reaction.  Incipient  cataract  in  each 
eye,  more  marked  in  right,  anterior  chambers,  normal  depth.  Intravenous 
injections  begun  September  10,  1  c.c.  beef-lens  vaccine;  September  15,  1 
c.c.  beef -lens  vaccine;  September  20,  1  c.c.  anti-human-lens  rabbit  serum; 
September  25,  2  c.c.  anti-human-lens  rabbit  serum;  September  30,  3  c.c. 
anti-human-lens  rabbit  serum;  October  5,  4  c.c.  anti-human-lens  rabbit 
serum.  No  reactions  from  treatment.  October  10,  2  c.c.  beef-lens  vaccine; 
October  15,  20,  25,  30,  5  c.c.  beef-lens  vaccine.  No  change  observed  in  the 
cataracts.  November  4,  1  c.c.;  November  9,  2  c.c.;  November  14,  3  c.c., 
and  November  19,  4  c.c.  anti-beef-lens  sheep  serum.  Following  this  last 
injection  patient  developed  temperature,  100;  pulse,  80;  respiration,  22, 
and  24  hours  later  a  severe  skin  eruption  which  covered  the  entire  body; 
there  were  large  red,  raised  spots  which  looked  like  a  severe  case  of  hives. 


Treatment  for  the  Prevention  and  Cure  of  Cataract  301 

November  24,  5  c.c.  anti-beef-lens  sheep  serum.  Patient  complained  of 
severe  headache  and  pains  in  his  back  and  legs;  temperature,  99.  Because 
of  reactions,  the  serum  from  December  4  was  given  subcutaneously.  De- 
cember 4,  1  c.c.  anti-beef-lens  sheep  serum;  December  9, 1  c.c.;  December  14, 

2  c.c.;   December  19,  3  c.c.;   December  24,  4  c.c.     Immediately  before  this 
last  injection,  blood  pressure,   118-76;    pulse,   76;    after,  blood  pressure, 
128-70.     Differential  blood  count:    No.  cells,  214;   poly.,  35.5;   lym.,  60.8; 
1.  mon.,  3.7;    hem.,  71%.     Examination  of  the  patient's  eyes  showed  no 
change  one  way  or  the  other  in  the  lens  opacities,  seemingly  the  cataracts 
had  been  arrested  in  development.     However,  the  patient  had  not  been 
under  observation  long  enough  to  determine  this. 

CASE  10. — Sherwood  F.,  admitted  December  14,  1918,  aged  sixty-three 
years  at  that  date.  English,  widowed,  well  nourished  and  in  good  physical 
condition.  Right  eye  has  incipient  cataract,  left  eye  almost  mature  gray 
cataract,  anterior  chamber  slightly  shallow  each,  more  marked  left,  right 
pupil  normal  in  size  and  reaction,  left  slightly  irregular.  V.  R.  E.,  20/200; 
L.  E.,  1.  p.,  projection  good.  Began  with  intravenous  injections  of  beef-lens 
vaccine.  September  15,  1921,  1  c.c.;  September  25,  2  c.c.;  September  30, 

3  c.c.;   October  5,  4  c.c.;   October  10,  2  c.c.;   October  15,  20,  25,  30,  5  c.c. 
November  1,  no  change  in  the  cataracts.     November  4,  1  c.c.  anti-beef-lens 
sheep  serum;   November  9,  2  c.c.  serum;   November  14,  3  c.c.  serum.     Ex- 
amination of  the  eyes  shows  slight  increase  of  vision  in  each.     R.  E.,  20/70; 
L.  E.,  1/200.     November  19,  4  c.c.  anti-beef-lens  sheep  serum.     Following 
this  injection  there  was  a  general  flushing  of  the  skin  of  the  whole  body, 
temperature,  100.6;   pulse,  96;   respiration,  26.     November  24,  5  c.c.,  and 
November  29, 1  c.c.  anti-beef-lens  sheep  serum;  one  or  two  drops  of  the  serum 
introduced  intradermally  gave  decided  local  reaction  (positive  sensitization 
test).     Because  of  the  reaction  injections  were  given  subcutaneously.     De- 
cember 4,  1  c.c. ;  December  9, 1  c.c. ;  December  14, 2  c.c. ;  December  19, 3  c.c. ; 
December  24,  4  c.c.     Immediately  before  this  last  injection,  blood  pressure, 
162-80;    pulse,   60;    after,  blood  pressure,   150-110.     Blood    examination: 
No.  cells,  220;  poly.,  55;  lym.,  27.7;  1.  mon.,  5;  eos.,  10.9;  bas.,  1.4;  hem., 
68%.     Examination  of  the  eyes  December  24  shows  slight  clearing  of  lens  in 
each,  but  not  pronounced. 

CASE  11. — James  S.,  admitted  August  25,  1921,  aged  fifty  years.  Irish, 
horseshoer,  well-nourished  man,  double  hernia.  Incipient  cataract  right, 
half  mature  left.  V.  R.  E.,  20  /40  - ;  L.  E.,  20  /200  + .  Pupils  slightly  slug- 
gish to  light,  anterior  chamber  normal  right,  shallow  left.  September  10, 
began  intravenous  injections  of  beef-lens  vaccine.  September  10,  15,  20, 
1  c.c.;  September  25,  2  c.c.;  September  30,  3  c.c.;  October  5,  4  c.c.;  October 
10,  2  c.c.;  October  15,  20,  25,  30,  5  c.c.;  no  change  in  cataracts.  November 
4,  1  c.c.  anti-beef-lens  sheep  serum;  November  9,  2  c.c.  serum;  November 
14,  3  c.c.  serum;  November  15,  clearing  of  opacities.  V.  R.  E.,  20/30; 
L.  E.,  20/200.  November  19,  4  c.c.  anti-beef-lens  sheep  serum.  Following 


302  A.  EDWARD  DAVIS 

this  injection  patient  developed  temperature,  102.6;  pulse,  102;  respiration, 
22,  and  showed  a  general  flushing  of  the  skin  over  the  entire  body.  No- 
vember 24,  5  c.c.,  and  November  29,  1  c.c.  anti-beef-lens  sheep  serum.  Intra- 
dermal  sensitization  test  positive.  Following  the  last  injection,  patient  de- 
veloped urticaria,  and  complained  of  pain  in  back  and  legs.  From  this  date 
on  injections  of  the  serum  were  given  subcutaneously.  December  4,  1  c.c. ; 
December  9,  1  c.c.;  December  14,  2  c.c.;  December  19,  3  c.c.;  December  24, 
4  c.c.  Immediately  before  the  last  injection,  blood-pressure,  102-78;  pulse, 
64;  after,  blood  pressure,  98-78.  Differential  blood  count:  No.  cells,  517; 
poly.,  46.4;  lym.,  41.8;  1.  mon.,  9.5;  eos.,  1.9;  bas.,  4;  hem.,  72%.  Decem- 
ber 24,  eyes  in  same  condition  as  of  November  15. 

CASE  12. — Joseph  H.,  admitted  August  9,  1921,  aged  eighty-two  years. 
German,  well-developed,  well-nourished  man,  systolic  heart  murmur,  absence 
knee  reflex,  epithelioma  left  side  nose.  Incipient  cataract  each  eye,  more 
marked  left.  V.  R.  E.,  20/100;  I,.  E.,  20/200.  Pupils,  right  larger  than 
left,  both  sluggish  to  light  stimulus;  good  for  accommodation.  September 
10  began  intravenous  injections  of  beef-lens  vaccine.  September  11,  15,  20, 
1  c.c. ;  September  25,  2  c.c. ;  September  30,  3  c.c. ;  October  4,  4  c.c. ;  October 
10,  2  c.c.;  October  15,  20,  25,  30,  5  c.c.;  November  1,  no  change  in  the 
cataracts.  November  4,  1  c.c.  intravenous  injection  of  anti-beef-lens  sheep 
serum;  November  9,  2  c.c.  serum;  November  14,  3  c.c.  serum;  November  19, 
4  c.c.;  November  24,  5  c.c.;  November  29, 1  c.c.;  December  4,  subcutaneous 
injections  of  anti-beef-lens  sheep  serum  were  begun.  December  4,  9,  1  c.c. ; 
December  14,  2  c.c. ;  December  19,  3  c.c.;  December  24, 4  c.c.  Immediately 
before  this  last  injection,  blood  pressure,  90-66;  pulse,  80;  six  hours  after, 
blood  pressure,  98-70.  December  24,  differential  blood  count:  No.  cells, 
.253;  poly.,  63.2;  lym.,  29.7;  1.  mon.,  6.7;  eos.,  .4;  hem.,  88%.  There  was 
but  little  change  produced  in  the  lens  opacities  by  the  treatment  and  vision 
was  unaltered.  The  patient  had  no  reactions  following  the  injections  either 
of  the  vaccines  or  serum. 

CASE  13. — Edward  B.,  admitted  in  1901;  good  physical  condition;  anoph- 
thalmos  right;  incipient  cataract  at  periphery,  inferior  nasal  quadrant,  left, 
pupil  normal  in  size  and  reaction.  V.,  20/20;  anterior -chamber  normal  in 
depth.  September  10,  intravenous  injections  of  beef-lens  vaccines  begun. 
September  10,  2  c.c.;  September  15,  20, 1  c.c.;  October  5, 10,  2  c.c.;  October 
15,  20,  25,  30,  5  c.c. ;  November  1  no  change  observed  in  the  cataract.  No- 
vember 4,  intravenous  injections  of  anti-beef-lens  sheep  serum  begun.  No- 
vember 4,  1  c.c.;  November  9,  2  c.c.;  November  14,  3  c.c.  V.,  20/15,  some 
clearing  of  opacity  in  the  lens.  November  19,  4  c.c.;  November  24,  5  c.c., 
and  November  29,  1  c.c.  anti-beef-lens  sheep  serum.  Intradermal  sensitiza- 
tion test  positive.  December  4,  subcutaneous  injections  of  the  sheep  serum 
were  begun.  December  4,  1  c.c.;  December  9,  1  c.c.;  December  14,  2  c.c.; 
December  19,  3  c.c.;  December  24,  4  c.c.  Immediately  before  this  last  in- 
jection, blood  pressure,  142-90;  pulse,  70;  after,  blood  pressure,  172-82. 


Treatment  for  the  Prevention  and  Cure  of  Cataract 


303 


Differential  blood  count:  No.  cells,  127;  poly.,  73-8;  lym.,  23;  1.  mon.,  2.3; 
eos.,  .9;  hem.,  67%.  Examination  of  the  eye  shows  little  change  in  lens 
opacity.  V.,  20/15. 

CASE  14. — This  case  is  of  interest,  as  here  the  treatment  was  given  inten- 
sively, that  is,  every  other  day.  Mrs.  W.,  aged  seventy-five  years;  a  mature 
senile  gray  cataract  in  the  right  eye.  The  left  lens  had  been  successfully 
extracted  twelve  years  previously.  Anti-beef-lens  sheep  serum  was  begun 
February  17,  1922,  intravenously,  the  initial  dose  being  %  c.c.,  which  was 
increased  %  c.c.  each  succeeding  dose.  The  patient  got  general  reaction 
after  the  sixth  dose,  which  was  3^  c.c.  of  the  serum.  March  17,  1922,  one 
month  after  the  injections  were  started,  there  were  marked  changes  in  the 
crystalline  lens.  Numerous  wedge-shaped  sectors  had  become  semitrans- 


Fig.  2.— Case  14.     Mrs.  W.     R.  E.;  two  stages. 

parent;  a  great  part  of  the  anterior  cortical  layers  was  absorbed,  so  that  a 
distinct  shadow  was  cast  on  the  nucleus  of  the  lens  by  the  iris  when  light  was 
focused  obliquely  into  the  pupillary  space.  One  month  later  the  effect  was 
even  more  pronounced  (Fig.  2).  In  fact,  more  effect  was  produced  on  the 
lens  of  this  patient  in  eight  weeks  of  intensive  treatment  than  in  any  of  the 
other  cases,  some  of  whom  have  been  under  treatment  for  fifteen  months.  It 
would  seem,  therefore,  that  a  quicker  and  more  effective  result  is  obtained  by 
intensive  treatment.  Guided  by  the  result  in  this  case,  just  as  soon  as  the 
serum  can  be  had  in  quantity,  which  the  manufacturers,  H.  K.  Mulford  &  Co., 
promise  in  the  near  future,  I  intend  to  start  the  treatment  with  a  massive 
intravenous  injection,  50  to  100  c.c.,  then  follow  it  up  with  injections  of  the 
vaccine  every  other  day.  In  this  way  it  is  hoped  to  obtain  a  very  decisive 
result  and  one  brought  about  in  a  reasonably  short  time — a  few  weeks. 


304  A.  EDWARD  DAVIS 

COMMENTS 

1 .  It  will  be  noted  in  these  experiments  that  both  sera  and  vaccines 
have  been  used,  and  in  some  patients  both  the  sera  and  vaccines  at 
different  periods  of  the  treatment;  also  at  the  beginning  of  the  experi- 
ments that  only  the  human  cataractous  lenses  were  used  as  vaccines, 
and  as  antigen  to  produce  anti-lens  sera.    Although  it  was  known  that 
the  lens  antigen  was  organ-specific  in  its  action,  nevertheless  it  was 
thought  that  lens  antigen  from  the  same  species  would  possibly  pro- 
duce a  more  powerful  serum  than  lens  antigen  from  a  foreign  species. 
Accordingly  at  first  only  the  human  lens  antigen  was  used.     Sub- 
sequently, because  of  the  difficulty  in  securing  sufficient  human  lens, 
beef  lens  antigen  was  used  in  the  preparation  of  anti-lens  sera.    The 
reason  for  changing  from  anti-lens  sera  to  lens  vaccines  in  the  same 
patient  was  twofold:  first,  the  intravenous  injection  of  serum,  when 
increased  up  to  5  c.c.,  and  sometimes  much  less  quantity  in  female 
patients,  caused  marked  anaphy lactic  shock;  second,  it  was  thought 
perhaps  that  the  active  stimulation  of  lens  antibodies  in  the  patient, 
by  injections  of  vaccines,  would  have  a  more  lytic  or  dissolving  action 
than  the  passive  treatment  by  means  of  the  small  amount  of  lens  anti- 
bodies contained  in  the  serum  injected. 

It  was  found  by  actual  experience,  however,  that  the  lens  vaccines 
also  produced  shock  when  given  intravenously  and  carried  up  to  as 
high  as  5  c.c.,  or  even  less  quantity.  Because  of  this  shock  effect, 
which  at  times  was  quite  alarming,  both  with  the  sera  and  vaccines 
when  given  intravenously,  we  finally  decided  to  give  all  injections,  sera 
and  vaccines,  subcutaneously.  Since  this  method  was  adopted,  no 
symptoms  of  shock  so  far  have  followed,  though  as  much  as  5  c.c. 
sera  or  vaccines  have  been  given  at  one  dose.  We  advise,  therefore,  for 
safety's  sake,  that  these  remedies  be  thus  given,  except  by  those  who 
are  quite  familiar  with  this  method  of  treatment. 

2.  Source  and  Strength  of  the  Sera. — Since  the  lens  is  organ-specific 
and  not  species-specific,  the  question  of  securing  sufficient  lens  antigen 
to  manufacture  anti-lens  serum  has  been  greatly  simplified,  as  beef, 
sheep,  and  swine  lenses  can  be  had  in  any  quantity;  and  sheep,  cows 
or  horses  even,  can  be  used  as  the  source  of  the  sensitized  serum.  In  our 
experiments,  instead  of  human  lenses  as  the  antigen,  and  rabbits  as 
the  source  of  the  sensitized  serum,  we  used  beef  lenses  as  the  antigen 
and  a  sheep  as  the  source  of  the  sensitized  serum.    This  is  a  practical 


Treatment  for  the  Prevention  and  Cure  of  Cataract  305 

method,  and  if  the  treatment  ultimately  proves  successful,  there  will 
be  no  lack  of  remedy  with  which  to  treat  patients. 

3.  Standardization  of  the  Sera. — So  far  we  have  not  been  able  to  have 
a  standardized  serum,  but  trust  to  have  this  later.  Guyer  and  Smith 
state  that  in  their  experiments,  inasmuch  as  they  had  no  visible  way 
to  tell  when  serum  is  adequately  sensitized  for  use  as  a  cytolysin  be- 
yond trying  it  out  directly,  a  series  of  lens  precipitin  tests  were  made 
with  various  of  the  fowls  (which  they  used  as  the  source  of  sensitized 
serum)  after  the  fifth  and  sixth  injections  of  antigen,  respectively,  in 
order  to  be  sure  they  were  responding  to  the  lens  proteins.  They  do 
not  claim  a  necessary  connection  between  the  precipitin  and  cytolysin 
reactions  of  the  blood,  but  it  is  thought  that,  if  the  lens  had  so  sensi- 
tized the  fowls  that  precipitins  were  formed,  one  might  infer  that 
cytolysins  had  also  been  generated.  It  is  possible,  therefore,  and 
feasible  to  test  the  animals — (rabbits,  sheep,  etc.)  we  are  now  using  as 
the  source  of  the  anti-lens  sera,  in  same  manner  to  determine  if  the  sera 
are  strongly  sensitized  with  cytolytic  substances. 

4-  General  Reactions. — First  to  be  considered  is  shock.  Several  of 
our  cases  suffered  more  or  less  severely  from  shock,  both  with  the  sera 
and  vaccines,  at  times  even  when  small  doses  were  administered  in- 
travenously. The  whole  surface  of  the  body  within  60  seconds  would 
turn  intensely  red,  then  after  a  few  moments  would  become  more  or 
less  livid,  labored  and  irregular  breathing  with  great  dyspnea,  rapid 
weak  pulse,  which  at  times  was  quite  irregular,  great  restlessness,  at 
first  quickly  followed  by  marked  general  weakness  and  in  the  severe 
cases  shock;  occasionally  there  was  involuntary  movement  of  the 
bladder  and  bowels.  Perhaps  the  most  distressing  symptom  was  that 
of  impending  suffocation.  The  blood  pressure  following  shock  varied ; 
in  most  of  the  cases  it  was  lowered ;  however,  in  others  it  was  elevated. 
As  regards  temperature,  unfortunately  this  was  taken  in  our  cases 
in  but  a  few  instances.  In  animals,  usually,  there  is  a  marked  drop  in 
the  temperature  following  shock,  and  Pfeiffer1  states  that  by  this 
symptom  alone  the  mildest  anaphylactic  reactions  may  be  detected 
even  when  other  symptoms  are  not  present. 

The  second  general  effect  of  the  prolonged  administration  of  anti- 
lens  sera  and  vaccines  is  that  of  anemia,  more  or  less  pronounced.  In 
one  of  our  cases  (Case  7),  the  second  to  have  the  treatment  (which 
extended  over  a  period  of  about  6  months),  the  patient  became  pale, 

1  Pfeiffer  u.  Mita:  Zeits.  f.  Immunitatsforschung,  1910,  iv. 
20 


306  A.  EDWARD  DAVIS 

lost  weight,  and  appeared  to  be  "  drying  up,"  as  one  of  the  staff  at  the 
hospital  remarked.  He  never  suffered  shock,  or  had  any  other  ill 
effect  from  the  injections,  except  that  he  gradually  lost  weight  without 
any  apparent  cause,  and  for  this  reason  alone  the  injections  were  dis- 
continued. This  patient's  differential  blood  count  was  not  tested  until 
December  24,  1921,  when  the  hemoglobin  was  78  per  cent. 

A  third  general  symptom  that  appeared  in  one  case  (Case  9)  was  an 
extensive  urticaria,  manifesting  itself  as  large  wheals,  an  inch  or  more 
in  diameter,  elevated  above  the  surrounding  skin  surface,  'and  cov- 
ering most  of  the  body,  which  lasted  a  few  days.  No  other  patient 
was  similarly  affected.  All  of  the  patients  treated,  except  one  or  two, 
responded  to  the  sensitization  tests  when  a  small  amount  of  the 
serum  or  vaccine,  with  which  they  were  being  treated,  was  injected 
intradermally. 

5.  Local  Reactions. — How  and  why  the  antibodies  contained  in 
sensitized  sera,  or  the  antibodies  produced  by  the  injection  of  the 
vaccines  directly  into  the  animal,  act  selectively  and  specifically  on  the 
tissues  used  as  antigen  are  still  conjectural.  All  we  know  definitely  is 
that  they  have  a  more  or  less  specific  action,  the  sera  acting  passively 
and  the  vaccines  actively.  Guyer  and  Smith1  in  their  extended  experi- 
ments on  pregnant  rabbits  and  mice  with  fowl  serum  sensitized  to 
rabbit  lens  and  mice  lens,  respectively,  have  noted  ©pacification  and 
liquefaction  of  the  lenses  of  the  young,  but  never  in  the  mothers,  who 
were  directly  injected.  In  the  case  of  one  young  mouse,  the  lens  in 
one  eye  was  rendered  opaque,  and  in  the  other  eye,  was  liquefied.  In 
no  instance  were  the  lenses  of  the  mothers  affected.  Their  comment 
relative  to  this  point  is  as  follows:  "In  so  far  as  the  literature  on  cy- 
tolysins  records  positive  results,  it  leads  one  to  expect  specific  effects 
in  the  immediate  animal  injected;  a  possible  explanation  of  the  lack 
of  effect  on  the  mother  may  be  that  because  of  the  meager-  circulation 
of  blood  in  the  lenses  of  adults,  the  quantity  of  cytolytic  serum  which 
reaches  a  lens  is  insufficient  to  affect  it." 

On  the  lenses  of  the  developing  young  in  utero,  as  is  well  known, 
there  is  a  vascular  membrane,  and  the  cytolytic  substance  can  reach 
these  lenses  and  have  a  much  greater  effect.  Furthermore,  such  devel- 
oping lenses  are  softer  and  have  not  the  fibrous  masses  as  obtains  in 
older  animals.  Guyer  and  Smith  attribute  the  liquefaction  of  lenses 
observed  by  them  in  the  young  of  rabbits  and  guinea-pigs  to  a  true 
1  Guyer  and  Smith:  Jour.  Experimental  Zoology,  May,  1918,  p.  681. 


Treatment  for  the  Prevention  and  Cure  of  Cataract  307 

cytolytic  action  of  the  sensitized  serum  used  by  them.  Whether  the 
clouding  and  opaquing  which  occurred  in  other  of  the  lenses  should 
be  regarded  as  the  result  of  a  cytolysin  or  of  a  precipitin,  they  regard 
as  problematical. 

A  further  possible  explanation  of  why  cytolytic  sera  do  not  affect  the 
lenses  of  adult  animals  or  man  powerfully,  may  be  due  to  the  lack 
of  alexin  or  complement  in  the  aqueous  humor  of  the  anterior  chamber 
of  the  eye.  This  curious  fact  is  called  attention  to  by  Zinsser,1  who 
cites  the  experiments  of  Metchnikoff :  "In  this  fluid  no  alexin  is  pres- 
ent under  normal  conditions,  but  if  puncture  is  practised  and  the 
fluid  again  taken  after  a  period  of  two  or  three  hours,  alexin  is  now 
found,  probably  according  to  Metchnikoff's  school,  because  of  the 
coincident  entrance  of  leukocytes  into  this  space.  It  is  conceivable, 
however,  that  the  aqueous  humor  may  be  free  from  alexin  for  other 
reasons  than  the  absence  of  leukocytes;  and  an  injury  followed  by 
the  invasion  of  leukocytes  is  pretty  sure  to  be  followed  also  by  the 
entrance  of  the  fluid  elements  of  the  blood,  i.  e.,  alexin." 

This  fact  would  suggest  one  practical  point  in  the  attempt  to  absorb 
or  liquefy  cataracts  in  the  human  animal,  that  is,  during  the  period 
that  the  vaccines  are  being  given,  the  eyeball  should  be  massaged,  or 
subconjunctival  injections  of  some  slightly  irritating  fluid  be  given.  In 
fact,  any  safe  means  employed  that  would  induce  an  increased  flow  of 
the  plasma  and  along  with  it  leukocytes  into  the  anterior  chamber  of 
the  eye;  because  it  is  absolutely  necessary  to  have  complement  or 
alexin  present  in  conjunction  with  the  antibodies  of  the  sensitized 
serum  in  order  to  obtain  a  lytic  effect — that  is,  absorption  or  liquefac- 
tion of  the  lens. 

6.  The  local  effects  of  sera  and  vaccines  on  the  cataractous  lenses, 
that  is,  as  regards  mature  and  immature  cataracts,  were  exactly  the 
opposite  to  what  we  had  preconceived  at  the  beginning  of  the  treat- 
ments. We  had  supposed  that  the  immature  cataracts  with  the  scat- 
tering or  partial  opacities  would  be  most  easily  affected.  It  proved  to 
be  exactly  the  contrary.  The  only  two  patients  in  whom  we  obtained 
partial  liquefaction  of  the  lenses  were  those  having  mature,  gray,  senile 
cataracts,  where  a  great  part  of  the  cortical  layers  was  absorbed. 
The  sera  and  vaccines  seemed  to  have  no  liquefying  effect  on  the 
spiculse  in  the  incipient  cases,  but  they  did  seem  to  exert  a  retarding 
effect  on  their  progress,>that  is,  they  seemed  to  prevent  further  develop- 
1  Zinsser:  Loc.  cit.,  p.  171. 


308  A.  EDWARD  DAVIS 

ment  of  the  cataracts.  This  was  obtained  particularly  in  case  No.  7. 
We  know,  however,  that  incipient  cataracts  may  remain  stationary 
for  years,  so  a  larger  number  of  cases  must  be  treated  and  a  more 
extended  time  allowed  to  ascertain  if  the  serum  actually  arrests 
development  of  immature  cataracts.  The  one  case  of  sclerosing  black 
cataract  was  not  affected  in  the  least  by  the  treatment.  Perhaps  a 
possible  explanation  of  the  more  marked  effect  on  mature  senile  cata- 
racts is  that  the  fibers  are  more  or  less  disintegrated,  and  the  broken 
down  fibers,  for  that  reason,  can  be  more  easily  liquefied. 

Perhaps  more  rapid  and  satisfactory  effects  could  be  obtained  if 
the  patients  received  more  intensive  treatment,  that  is,  to  give  the 
injections  every  other  day  for  two  weeks,  then  rest  a  week,  and  again 
repeat  the  injections  for  two  weeks.  However,  this  remains  for  the 
future. 

7.  It  may  be  asked  by  some,  why  should  these  insane  patients 
blinded  by  cataracts  be  subjected  to  more  or  less  risky  treatment? 
For  two  reasons :  first,  many  of  the  patients  cannot  be  operated  upon 
for  the  cataract  because  of  their  disturbed  condition,  the  patient 
destroying  the  eye  at  the  time  of  the  operation,  or  subsequently,  be- 
fore the  wound  is  healed,  by  his  violent  actions.    No  such  risk  to  the 
eye  is  incurred  when  vaccines  and  immunized  sera  are  given;  second, 
when  these  anti-lens  sera  and  lens  vaccines  are  given  subcutaneously  or 
deep  into  the  tissue,  no  more  risk  is  incurred  to  the  patient's  general 
condition  than  is  now  taken  daily  by  injecting  the  various  bacterial 
vaccines  and  sera,  for  instance,  diphtheria  antitoxin.     The  general 
condition  of  these  insane  patients  is  often  greatly  improved  by  the 
removal  of  cataracts;  therefore,  if  we  can  devise  a  safe  means  for  the 
absorption  of  their  cataracts,  even  in  the  most  disturbed  cases,  we  will 
have  accomplished  a  great  advance  in  their  treatment.    Furthermore, 
the  full  consent  of  relatives  or  friends  was  obtained  before  these  experi- 
ments were  started. 

8.  Twelve  of  these  patients  were  bled  on  December  24,  1921,  and 
precipitin  tests  on  their  sera  were  made,  which  proved  rather  incon- 
clusive, as  serum  in  Case  No.  2  was  negative  in  all  the  dilutions  of  the 
serum.     On  the  other  hand,  in  Case  No.  3  the  test  was  positive  in 
dilution  1 : 10;  in  Case  No.  9  +  in  dilution,  1 : 100,  and  in  Case  No.  11, 
+  in  dilution  1 : 100.    It  will  be  noted  in  case  reports  that  the  lenses  in 
Cases  3  and  9  were  not  affected  by  the  treatment,  while  in  Case  11 
only  slight  effect  was  produced  on  the  lens. 


Treatment  for  the  Prevention  and  Cure  of  Cataract 


309 


PRECIPITIN  TESTS  ON  SERA  OF  PATIENTS  TREATED  WITH  LENS 

ANTIGEN 


No.  of  Case 

Dilution  of 
Lens  Antigen 

Dilution  of  Serum 

1 

1:10 

1:10 

1:100 

1:200 

2 

— 

— 

— 

3 

+ 

— 

— 

4 

— 

— 

— 

5 

— 

— 

— 

6 

— 

— 

— 

7 

— 

— 

— 

9 

— 

+ 

— 

10 

— 

— 

— 

11 

— 

+ 

— 

12 

— 

— 

— 

13 

CONCLUSION 

No  definite  conclusions  can  be  drawn  from  so  few  cases  (13)  as  here 
reported.  The  partial  results  so  far  obtained  would  seem  to  indicate : 
First,  that  mature  senile  cataracts  (at  least  the  cortical  layers)  may  be 
absorbed  or  liquefied ;  second,  a  possibility  that  immature  cataracts 
may  be  retarded  or  entirely  checked  in  their  progress.  The  present 
paper  is  to  be  considered  simply  as  a  preliminary  report,  to  be  followed 
by  further  and  more  extended  experiments. 

I  cannot  close  the  paper  without  expressing  my  deep  appreciation 
of  the  assistance  given  me  by  Dr.  Russell  L.  Cecil,  who  prepared  the 
sera  and  vaccines  and  gave  valuable  suggestions  in  the  method  of  ad- 
ministration, and  my  thanks  are  due  to  Dr.  George  A.  Smith,  Super- 
intendent of  the  State  Hospital  at  Central  Islip,  N.  Y.,  and  to  the  staff 
of  this  institution.  I  am  particularly  indebted  to  Dr.  Ralph  G.  Reed, 
Dr.  Charles  Vaux  and  Dr.  McNeill,  who  helped  conduct  the  treatment 
and  who  gave  many  of  the  injections.  Without  their  assistance  the 
treatment  could  not  have  been  carried  on.  The  pathologist  of  the  in- 
stitution, Dr.  King,  made  the  differential  blood  counts  and  hemo- 
globin tests. 

DISCUSSION 

DR.  LUCIEN  HOWE  (Buffalo,  N.  Y.) :  In  dealing  with  this  question,  it  seems 
essential  to  remember  that  the  lens  is  a  complex  substance.  The  chemists 
tell  us  it  contains  at  least  five  different  proteins.  What  the  action  of  one 
may  be  as  compared  with  another  as  yet  we  know  not. 

It  is  quite  sure,  however,  that  in  one  way  the  lens  does  act  as  a  lysin.     That 


310  A.  EDWARD  DAVIS 

is  shown  by  the  experiments  of  Guyer.  But  this  action  may  prove  to  be  a 
two-edged  sword.  Although  we  may  sometimes  obtain  action  on  the  lens 
which  we  wish,  we  may  also  get  a  severe  anaphylactic  action  otherwise,  and 
destroy  other  parts  of  the  eye.  This  is  a  new  subject,  one  that  gives  us  hope 
for  the  future.  But  at  present  the  only  patients  who  will  consent  to  be 
treated  in  that  way,  according  to  the  doctor's  report,  are  those  who  are  al- 
ready in  an  insane  hospital.  All  that  can  be  said  is  that  for  the  present  the 
curtain  is  drawn  aside  and  we  get  a  glimpse  of  the  great  field  for  investiga- 
tion that  lies  beyond. 

PROF.  M.  F.  GUYER  (Madison,  Wis.) :  I  know  nothing  about  the  clinical 
or  the  pathologic  aspects  of  this  problem.  I  am  a  mere  biologist,  but  I  have 
been  interested  in  Dr.  Davis'  report,  particularly  in  connection  with  his  use 
of  vaccines.  In  our  own  case,  as  he  has  said,  we  observed  no  direct  effect 
on  the  eyes  of  the  injected  mother  rabbits.  But,  as  a  matter  of  fact,  we 
judged  largely  by  obvious  defects.  We  have  not  tried  to  go  into  the  refine- 
ments of  the  question;  we  have  gone  largely  by  conspicuous  marks  like  a 
cataractous  lens. 

In  our  experience  defects  were  produced  first  in  the  uterine  young.  We 
timed  our  injections  so  as  to  get  them  into  the  pregnant  mother  about  the 
time  the  lens  was  forming  at  its  best  in  the  young,  which  means  about  the 
tenth  to  the  fourteenth  day.  It  is  surrounded  then  by  a  network  of  blood- 
vessels, and  anything  we  got  through  the  placenta  could  easily  reach  the  lens 
by  means  of  the  circulating  blood.  Lens-defects  established  in  this  way 
apparently  became  hereditary. 

The  thing  that  has  interested  me  most  in  Dr.  Davis'  account  is  that  he  gets 
direct  effect  on  the  mother.  And  the  paper  of  Drs.  Verhoeff  and  LeMoine 
also  speaks  of  the  fact  that  where  you  have  an  injured  lens  you  are  likely  to 
get  sensitization.  This  suggests  that  a  lytic  substance  may  have  been  pro- 
duced in  the  blood  stream;  and  may  not  such  lytic  substances  operate  on  the 
cells  of  the  young  in  pregnant  females  so  as  to  form  the  beginning  of  congenital 
defects?  Certainly  in  the  eyes  of  some  of  our  fetal  rabbits  we  secured  such 
an  effect.  This  occurred  not  only  after  the  injection  of  fowl-serum  immunized 
against  rabbit  lens,  but  also  when  we  injected  rabbit-lens  directly  into  preg- 
nant rabbits.  It  is  difficult  to  get  the  defect  in  the  latter  way.  One  female 
so  treated,  however,  has  three  defective-eyed  young.  This  opens  up  the 
whole  field  of  congenital  defects  in  the  first  place.  If  an  animal  can  build  up 
antibodies  against  its  own  tissues  when  these  become  injured  or  diseased,  and 
if  such  antibodies  can  also  affect  the  fetus  or  the  gonads,  you  see  where  the 
facts  lead.  Our  work  with  rabbits  tends  to  make  us  believe  that  there  is 
some  thread  of  chemical  identity  between  substances  in  the  germ-plasm  and 
the  finished  organ  in  the  adult.  And  if  you  get  a  lytic  effect  in  one  may  you 
not  get  a  like  action  in  the  other? 

DR.  HENRY  H.  TYSON  (New  York  City) :  Clinically,  the  subject  of  Dr. 
Davis'  paper  is  one  of  interest  not  only  to  ophthalmologists  but  to  those  who 
may  be  afflicted  with  cataracts,  for  individuals  if  given  their  choice  between 
medical  and  surgical  treatment,  with  anticipated  equal  results,  will  in  a  vast 
majority  of  cases  select  the  former  procedure.  This  being  so,  it  can  be 


Treatment  for  the  Prevention  and  Cure  of  Cataract  311 

readily  seen  how  important  these  preliminary  researches  may  be,  providing 
the  future  should  fulfil  Dr.  Davis'  fondest  hopes. 

Unfortunately,  in  my  opinion,  the  results  so  far  obtained  and  reported  are 
too  few  and  of  too  short  duration  to  enable  us  to  form  reliable  conclusions. 
All  of  us  have  seen  quite  similar  results  in  cases,  some  with  no  treatment  and 
others  under  what  might  be  termed  ordinary  routine  tonic  treatment. 

Guyer  and  Smith,  in  their  researches  in  animal  experimentation,  demon- 
strated the  fact  that  while  lens  serum  did  not  apparently  affect  the  eyes  of 
the  adult  animal  injected,  it  did  produce  anatomic  changes  in  the  eyes  of 
the  offspring.  Dr.  Davis,  however,  with  his  method  thinks  he  finds  that  the 
cortex  of  the  cataractous  lenses  of  human  adults  is  acted  upon  with  similar 
serums  and  vaccines.  Assuming  this  to  be  a  fact,  much  progress  still  remains 
to  be  made  in  finding  a  solvent  for  the  nucleus  of  the  lens  before  it  could 
assume  a  definite,  practical  therapeutic  value. 

That  spontaneous  absorption  of  cataractous  lenses  may  occur  I  can  testify 
from  a  recent  personal  observation  of  an  unrecorded  case  in  a  physician  aged 
forty  years,  with  soft  cataract  and  an  uveitis  anterior,  who,  while  under  treat- 
ment with  thyroid  extract  and  tuberculin  therapy  for  the  latter  condition, 
had  his  cataractous  lens  absorbed,  leaving  only  the  capsule  remaining. 
There  was  no  history  nor  evidence  of  traumatism  while  under  observation. 

If  Dr.  Davis'  future  researches  should  prove  that  he  can  at  will  aid  or 
induce  nature  to  produce  results  similar  to  the  foregoing  case  with  his  method 
of  vaccine  and  serum  therapy,  he  will  then  have  added  a  very  important  and 
valuable  chapter  to  the  history  of  "bloodless  surgery  of  the  eye." 

DR.  FREDERICK  A.  DAVIS  (Madison,  Wisconsin) :  What  I  have  to  say  has 
only  an  indirect  bearing  on  the  subject,  as  it  deals  exclusively  with  rabbits  in 
which  hereditary  blindness  has  been  produced  by  the  injection  of  fowl  serum 
immunized  against  rabbit  lens,  or  by  direct  injection  of  lens  into  the  pregnant 
mother,  after  the  method  of  Dr.  Guyer. 

Recently  I  have  undertaken,  with  my  associate,  Dr.  Neff ,  the  study  of  all 
the  defective-eyed  stock  in  Dr.  Guyer's  laboratory.  To  date  we  have 
studied  about  20  pairs  of  eyes.  The  work  is  not  yet  finished,  and  therefore 
only  an  incomplete  report  can  be  given  at  this  time.  Of  the  rabbits  studied 
so  far  which  showed  some  abnormality,  six  had  one  normal  eye.  The  right 
eye  was  more  frequently  affected  than  the  left.  The  most  striking  and  more 
typical  changes  are  as  follows : 

The  globes  varied  in  size  and  shape  from  an  almost  total  absence  to  a  size 
somewhat  larger  than  normal,  the  atrophic  and  microphthalmic  globes  pre- 
dominating. The  tension  to  -palpation  was  usually  subnormal.  The 
conjunctivas  frequently  were  watery  and  injected.  The  sclera  often  showed 
marked  thinning  between  the  muscle  attachments,  with  a  staphyloma  in  the 
posterior  and  inferior  portion  of  the  globe.  This  was  so  great  at  times  that 
the  cornea  became  displaced  behind  the  lids,  the  large  staphylomatous  mass 
protruding  between  them. 

The  cornese  were  at  times  clear,  though  frequently  a  keratitis  was  present, 
especially  characterized  by  an  invasion  of  the  conjunctiva  at  the  limbus,  or 
an  appearance  resembling  sclerosing  keratitis.  The  central  portion  of  the 


312  A.  EDWARD  DAVIS 

cornea  often  showed  a  deep  opacity.  The  anterior  chamber  varied  in  depth, 
some  being  deep,  some  shallow.  They  were  usually  deep  where  the  globe 
was  not  atrophic. 

The  iris,  with  one  exception,  showed  a  large  coloboma  below.  They 
appeared  atrophic  and  usually  did  not  react  to  light.  Abnormal  vasculariza- 
tion  was  present  in  some  instances. 

The  lens  usually  showed  some  form  of  opacity,  varying  from  discrete 
cortical  spots  to  a  general  diffuse  cloudiness,  and  at  times  an  appearance  of 
calcareous  degeneration.  One  post-polar  cataract  was  observed.  The 
lenses  appeared  to  be  dislocated  below  and  backward  in  the  colobomatous  area. 
No  liquefaction  or  absorption  of  the  lens  has  yet  been  found  in  this  series. 

The  vitreous  was  usually  apparently  clear  in  the  upper  portions  of  the 
globe,  but  in  the  lower  half  it  was  filled  with  masses  of  vascularized  tissue  or 
exudate,  especially  in  the  region  of  the  coloboma.  Numerous  blood-vessels 
could  be  seen  in  these  masses,  and  they  often  appeared  to  run  forward  in  an 
anteroposterior  direction. 

The  choroid  practically  always  showed  a  broad  coloboma  below,  spreading 
from  the  nerve-head  through  the  ciliary  body.  The  normal  arrangement  of 
the  choroidal  vessels  could  be  made  out  above  the  disc  with  the  ophthal- 
moscope. The  margins  of  the  coloboma  were  often  clear-cut  and  sharply 
defined,  but  a  clear  view  of  the  entire  colobomatous  area  was  obscured  by  the 
vascularized  masses  of  tissue  anterior  to  it. 

The  optic  nerve  head  and  retina  in  the  normal  eyes  showed  the  character- 
istic arrangement  of  the  medullated  nerve-fibers,  with  an  unusually  deep 
cupping  of  the  entire  disc,  varying  in  depth  from  4  D.  to  9  D.  In  the  diseased 
eyes  only  the  upper  margins  of  the  disc  could  be  made  out,  the  lower  portions 
merging  with  the  coloboma  of  the  choroid  below.  We  have  not  yet  deter- 
mined whether  or  not  there  is  a  coloboma  of  the  retina  and  optic  nerve. 
There  was  a  rather  striking  absence  of  hemorrhages  except  in  one  baby 
rabbit.  The  retinae  were  apparently  normal  in  the  upper  part  of  the  eye. 

It  is  interesting  to  note  that  these  more  or  less  typical  changes  were  already 
present  in  the  eyes  of  a  baby  rabbit  of  two  months,  a  specimen  of  which  I 
have  with  me. 

DR.  A.  E.  DAVIS  (closing) :  I  realize  the  two-edged  sword  that  Dr.  Howe 
spoke  of.  Some  years  ago  I  consulted  with  Dr.  Flexner,  of  the  Rockefeller 
Institute,  and  he  also  mentioned  the  same  point.  In  fact,  that  is  one  of  the 
reasons  I  gave  up  the  experiments  in  the  early  part  of  them.  However,  after 
I  had  seen  the  results  of  Guyer  and  Smith  I  did  not  hesitate  to  go  on.  As 
Dr.  Howe  has  said,  the  most  of  them  were  on  insane  patients.  I  may  say, 
however,  that  I  have  now  five  private  patients  who  have  come  and  asked  to  be 
treated.  It  is  a  rare  thing  when  a  patient  comes  in  with  cataract  and  wants 
to  be  operated.  Like  the  old  colored  gentleman  down  South,  they  usually 
ask  if  you  cannot  "scatter"  it.  We  hope  to  make  the  operation  for  cataract 
obsolete. 


FACOERISIS 

PROF.  IGNACIO  BARRAQUER 

Barcelona,  Espana 

Daviel,  al  idear  la  extraccion  de  la  catarata,  se  proponia  hacer  la 
extraccion  total,  pero  dificultades  tecnicas  le  impidieron  llevar  a  cabo 
su  deseo,  quedando  instituido  desde  entonces  el  me'todo  clasico  por 
quistitomia,  que  se  ha  practicado  con  muchas  modificaciones  en  su 
tecnica,  todas  ellas  encaminadas  a  extraer  la  mayor  cantidad  posible 
de  restos  blandos  y  capsula  del  cristalino,  con  el  minimum  de  manio- 
bras.  Prueba  evidente  del  profundo  convencimiento,  que  en  el 
animo  de  todos  los  oftalmologos  existe  de  que  la  mayor  parte  de 
accidentes  operatorios  son  debidos  a  las  multiples  maniobras,  que  re- 
quiere  una  evacuaci6n  completa  de  masas  (presiones,  lavados,  iridec- 
tomia,  etc.),  y  de  que  los  accidentes  post-operatorios  reconocen  por 
origen  las  flogosis  determinadas  por  dichos  restos  y  los  enclavamientos 
•  de  los  mismos. 

A  pesar  de  todas  las  modificaciones  llevadas  a  cabo  en  la  quistitomia 
y  de  las  operaciones  complementarias  ideadas  (iridectomia  prepara- 
toria,  discision,  etc.),  para  obtener  los  resultados  de  una  operacion 
perfecta,  nunca  con  dicho  metodo  se  puede  lograr  este  ideal,  toda  vez 
que  s'empre  dentro  del  ojo  quedan  restos  de  la  lesion  que  nos  pro- 
ponemos  extirpar. 

La  extraccion  simple  total  es  el  unico  metodo  racional  que  existe 
para  operar  la  catarata.  Esta  se  ha  practicado  por  muchos  procedi- 
mientos  que,  si  bien  libraban  al  ojo  de  los  accidentes  post-operatorios, 
por  dejarle  libre  de  restos  de  catarata,  le  predisponian  a  accidentes 
operatorios,  por  complicar  las  maniobras  del  acto  quirurgico. 

Convencido  de  que  unicamente  debfamos  practicar  la  extraccion 
total,  ensaye  la  mayor  parte  de  los  metodos  existentes  durante  varies 
anos,  cerciorandome  de  que  los  menos  expuestos  eran  los  que,  cogiendo 
el  cristalino  por  su  cara  anterior,  lo  extraian  fuera  del  ojo,  envuelto 
en  su  cdpsula,  si  bien  los  instrumentos  para  ello  ideados  rasgaban  la 
cdpsula  cristaliniana,  convirtiendo  en  la  mayoria  de  casos  la  tan 
deseada  extraccion  total  en  una  simple  quistiectomia ;  era  pues  pre- 
313 


314  IGNACIO  BARRAQUER 

ciso  construir  una  pinza  que  no  rompiera  la  cdpsula  del  cristalino. 
Esta  fue  mi  idea  primordial  del  procedimiento  que  denomine  Faco- 
erisis,  del  griego  Faco,  lente  y  Erios,  arrancar.  Una  pequena  ventosa 
adaptada  a  la  cara  anterior  del  cristalino  debia  hacer  presa  fuerte- 
mente  en  el  y  permitir  arrancarlo,  rompiendo  las  debiles  fibras  de  la 
zonula  que  le  mantienen  en  su  sitio.  Muchas  fueron  las  tentativas 
y  pruebas,  que  lleve  d  cabo  variando  la  forma  y  dimensiones  de  la 
ventosa  y  la  intensidad  del  vacio;  antes  de  lograr,  coger  y  sacar 
enteras  las  cataratas  con  un  minimum  aceptable  de  rupturas  de  su 
cdpsula  pero  sin  embargo  las  tracciones  que  sobre  la  insercion  peri- 
f erica  de  las  fibras  zonulares  se  practicaban,  predisponian  al  ojo  a 
complicaciones  por  parte  de  la  region  ciliar.  Mi  metodo,  distaba 
mucho  de  la  perfeccion,  si  bien  obtenia  con  el  resultados  superiores  d 
los  de  la  quistitomia. 

Mi  primer  Erisifaco  era  una  pinza  pneumatica,  mientras  que  el 
actual  es  pinza  pneumdtica  y  zonulotomo  toda  vez  que  al  coger  el 
cristalino  y  deformarle,  reduciendo  su  didmetro  mdximo,  lo  hace  por 
pequenas  y  frecuentes  sacudidas,  con  las  que  se  le  imprime  un  movi- 
miento  vibratorio  rapidisimo,  y  de  suficiente  altura  de  onda,  para 
que  al  ser  transmitido  d  las  fibras  zonulares  ocasionen  su  ruptura 
cerca  del  cristalino,  sin  que  la  fuerza  tenga  tiempo  de  transmitirse  d 
su  insercion  periferica,  y  sin  que  la  intensidad  de  vacio  empleada  sea 
capaz  de  romper  la  elasticidad  de  la  capsula,  rompiendola.  Claro 
esta  que  dicha  intensidad  de  vacio  (altura  de  la  vibracion)  y  el  numero 
de  interrupciones  por  minuto  (amplitud  de  la  vibracion)  son  condi- 
ciones  mecanicas  del  enrarecimiento  del  aire  en  la  ventosa,  que  deben 
guardar  relacion  con  las  condiciones  ffsicas  de  cada  uno  de  los  ojos  d 
operar,  y  que  el  operador  debe  regular  de  antemano  en  su  Erisifaco, 
con  arreglo  a  la  mayor  o  menor  dureza  del  cristalino  y  esclerosis  de  la 
zonula. 

Las  alturas  de  onda  (intensidad  de  vacio),  que  empleamos,  estan  en 
razon  directa  de  la  mayor  dureza  del  cristalino,  y  la  amplitud  de  las 
vibraciones  (numero  de  las  mismas)  en  raz6n  inversa  de  la  mayor 
esclerosis  de  las  fibras,  de  modo  que  en  una  catarata  incompleta, 
blanda,  deformable,  con  una  zonula  eldstica  poco  esclerodada,  debemos 
emplear  un  vacio  debil  y  un  numero  de  vibraciones  grandes,  mientras 
que  en  los  sujetos  viejos  con  cataratas  completas  y  zonulas  friables, 
hace  falta  mayor  intensidad  de  vacio  para  deformar  el  cristalino  y 
siendo  menos  elastica  su  zonula,  necesita  menor  numero  de  vibraciones 
para  romperse. 


Facoerisis  315 

A  pesar  de  haber  logrado  la  extraccion  sin  tracciones  en  la  insercion 
periferica  de  la  zonula,  se  veian  mis  estadisticas  afeadas  por  alguna 
iridociclitis  tardia,  iridociclitis  debida  al  enclavamiento  en  los  labios 
de  la  herida  de  las  fibras  zonulares  o  de  los  angulos  del  coloboma 
quirurgico.  Complicacion  que  raramente  se  presentaba  en  los  casos 
operados  sin  iridectomia,  por  lo  que,  salvo  en  casos  escepcionales, 
hago  la  extraccion  simple  con  una  pequena  brecha  periferica  en  el 
iris  para  evitar  la  hernia. 

Las  maniobras  operatorias  en  una  Facoerisis  simple,  quedan  re- 
ducidas  a  la  mas  minima  espresi6n,  pues  que  una  vez  tallado  el 
colgajo,  basta  introducir  en  la  camara  anterior  un  solo  instrumento, 
el  Erisifaco,  que  aplicado  sobre  la  cara  anterior  del  cristalino  adhiere 
a  ella  y  lo  libra  de  sus  naturales  adherencias,  sin  que  el  ojo  se  deforme, 
sin  la  menor  violencia,  y  con  solo  retirar  el  instrumento  de  la  camara 
anterior,  con  suavidad  pasmosa  se  ve  salir  el  cristalino  envuelto  en  su 
capsula,  adherido  d  su  extremidad  quedando  la  pupila  de  un  negro 
purisimo,  central  y  redonda. 

Las  reacciones  post-inflamatorias  debidas  en  la  quistitomia:  1°  d 
las  repetidas  maniobras  del  acto  quirurgico,  2°  a  los  restos  de  sub- 
stancias  degeneradas  del  cristalino  y  su  capsula,  y  3°  d  los  enclava- 
mientos  de  restos  de  la  capsula  entre  los  labios  de  la  herida,  no  existen, 
toda  vez  que  con  una  sola  maniobra  extirpamos  de  una  vez  toda  la 
lesion,  sin  dejar  dentro  del  ojo  el  menor  resto  de  ella. 

La  presencia  de  restos  cristalinianos  en  el  humor  acuoso  y  la 
flogosis  que  ellos  originan,  convierten  &  la  camara  anterior  en  un 
terreno  abonado  a  los  germenes  infectivos,  condiciones  que  no  existen 
en  la  extraccion  total,  por  lo  que  las  infecciones  en  esta  clase  de 
operacion  son  rarisimas. 

La  tecnica  de  la  operacion  es  f  acil,  pero  requiere  una  serie  de  pequenos 
detalles  indispensables  para  el  buen  resultado.  Los  enfermos  son 
examinados  detenidamente,  con  la  pupila  dilatada,  al  microscopic 
binocular  y  lampara  de  hendidura,  a  fin  de  conocer  las  earacterfsticas 
del  cristalino,  su  cdpsula,  y  la  zonula,  que  nos  han  de  permitir  graduar 
la  intensidad  del  vacio  y  el  mimero  de  vibraciones  por  minuto,  con 
que  debe  llevarse  a  cabo  la  inter  vencion,  asi  como  tambien  el  tiempo 
necesario  para  obtener  la  dilatacion  pupilar  deseada  y  asesorarnos 
de  que  el  ojo  reune  las  condiciones  de  asepsia  necesarias  para  sufrir 
una  intervencion. 

Previa  dilatacion  pupilar  por  un  midri&tico  de  acci6n  fugaz  (euftal- 
mina),  tallamos  con  el  cuchillo  de  Graeffe  un  colgajo  de  los  f  de  la 


316  IGNACIO  BARRAQUER 

circunferencia  de  la  cornea,  emplazando  en  ella  sus  dos  tercios  estro- 
mos  y  el  tercio  medio  en  la  esclerotica,  acabdndolo  con  una  larga 
lengueta  conjuntival,  en  la  que,  si  lo  creemos  indicado,  emplazamos 
un  punto  de  sutura  que  anudaremos  despue"s  de  terminada  la  opera- 
cion.  Si  esta  debe  ser  simple,  introducimos  en  la  cdmara  anterior, 
rozando  la  cara  posterior  de  la  cornea,  sin  tocar  el  iris,  la  pequena 
ventosa  del  Erisifaco,  previamente  regulado  con  arreglo  a  las  con- 
diciones  fisicas  del  ojo  d  operar,  y  al  nivel  del  centre  de  la  pupila  se 
aplica  sobre  la  cristaloides  sin  ejercer  la  menor  presion,  y  la  hacemos 
resbalar  hacia  abajo  hasta  que  su  estremo  inferior  se  oculta  debajo 
del  iris,  en  la  cdmara  posterior;  entonces  es  cuando  abriendo  paso 
al  vacio,  se  produce  el  enrarecimiento  del  aire  en  la  ventosa  d  la  que 
se  adhiere  el  cristalino,  rompiendose  instantaneamente  las  fibras  de  la 
zonula.  Con  suma  lentitud  y  sin  hacer  nunca  la  menor  presion  sobre 
el  vitreo.  hacemos  que  el  cristalino  gire  sobre  un  eje  transversal  hasta 
que  su  borde  inferior,  rozando  la  cara  posterior  del  iris  primero  y  la 
de  la  cornea  despues,  se  convierta  en  superior  en  cuyo  momento,  con 
solo  retirar  el  instrumento  del  ojo  acabamos  la  extraccion,  quedando 
la  toilette  reducida  a  la  aplicacion  de  la  pomada  de  eserina  para  que 
el  miosis  producido  prive  el  enclavamiento  de  las  fibras  zonulares. 

Si  la  talla  del  colgajo  y  la  maniobra  de  extraccion  han  sido  efec- 
tuadas  con  suavidad  y  sin  hacer  la  menor  presion  sobre  el  globo  ocular, 
nunca  tendremos  perdidas  de  vitreo,  ni  accidentes  operatorios,  a  no 
ser  que  el  paciente  contraiga  el  orbicular  de  los  parpados  o  haga 
movimientos  intempestivos.  Para  evitar  con  toda  seguridad  los 
movimientos  que  por  la  indocilidad  del  paciente  pudieran  sobrevenir, 
provocamos  como  Van  Lint  y  Villard  la  paralisis  temporal  del  orbicu- 
lar. 

Aunque  soy  partidario  entusiasta  de  la  extraccion  simple,  practice 
en  casi  todos  mis  enfermos  un  pequeno  agujero  en  la  periferia  del  iris, 
que  sin  privarnos  de  las  ventajas  de  aquella,  nos  da  las  garantias  de 
la  iridectomia  en  cuanto  a  la  hernia  del  iris. 

Regulando  apropiadamente  la  intensidad  de  vacio  y  mimero  de 
vibraciones,  pueden  extirparse  sin  temor  d  accidente  alguno,  toda 
clase  de  cataratas  (maduras,  incipientes,  Morganianas,  etc.)  en  su- 
jetos  mayores  de  40  anos  de  edad,  y  en  sujetos  mas  jovenes  todas  las 
completas  y  aun  algunas  variedades  de  las  incompletas  en  que  la 
zonula  se  presenta  muy  esclerosada.  Las  cataratas  polares  posteri- 
ores  sintomdticas  de  la  miopia,  se  extraen  con  facilidad  ya  que  la 
zonula  en  ellas  es  muy  fr&gil. 


Facoerisis  317 

Llevo  practicadas  mds  de  2800  Facoerisis  y  los  unices  accidentes 
operatorios  que  en  estos  ultimos  tiempos  registran  mis  estadisticas 
son  los  siguientes:  1.  Dificultad  de  practicar  la  iridectomia  peri- 
ferica  que  se  convierte  en  total,  por  exceso  de  dilatacion  pupilar, 
resultando  que  hemos  practicado  involuntariamente  una  extraccion 
combinada.  Rarisimo,  si  los  enfermos  estan  bien  preparados.  2. 
Despues  de  tallado  elcolgajo,  algunas  veces  la  pupila  se  contrae  de- 
masiado,  dificultando  el  emplazamiento  de  la  ventosa,  lo  que  sin  em- 
bargo se  logra  con  un  poco  de  habilidad.  Caso  de  coger  el  iris  entre 
la  ventosa  y  el  cristalino  basta,  despues  de  haber  dado  la  vuelta  al 
cristalino  dentro  de  la  camara  anterior,  interrumpir  el  paso  del  vacio, 
permitiendo  la  entrada  en  la  ventosa  de  la  presion  atmosferica  para 
que  suelte  la  catarata,  y  cogerla  nuevamente.  3.  Rotura  de  la 
capsula.  (a)  Esta  puede  ser  instantanea  al  coger  la  catarata,  lo  que 
significa  que  nos  hemos  equivocado  empleando  un  vacio  demasiado 
intense.  Ocurre  raramente.  (b)  En  aquellos  sujetos  jovenes  con 
zonula  muy  resistente,  puede  abrirse  el  saco  capsular  por  su  borde 
inferior,  y  si  bien  es  extraida  la  capsula  entera,  su  micleo  y  gran 
cantidad  de  masas,  quedan  en  las  camaras  del  ojo  pequefios  restos 
de  substancia  blanda.  (c)  Al  acabarse  la  extraccion,  los  labios  del 
colgajo,  pellizcando  la  catarata,  pueden  romper  la  capsula;  en  este 
caso  el  contenido  del  saco  capsular  se  derrama  fuera  de  las  camaras 
del  ojo,  en  los  fondos  de  saco  conjunti vales.  Como  se  comprende,  la 
rotura  de  la  capsula  no  tiene  otro  inconveniente  que  el  convertir  la 
extraccion  total  en  una  quistiectomia.  Es  muy  poco  frecuente 
cuando  se  tiene  practica  en  el  procedimiento.  4.  Perdida  de  vitreo; 
unicamente  se  presenta  cuando  el  operador  hace  una  presion  indebida 
sobre  el  globo,  o  si  el  paciente  contrae  los  musculos  orbitarios.  Rarfs- 
ima,  con  la  paralisis  temporal  del  orbicular. 

Las  complicaciones  post-operatorias,  si  la  operacion  ha  sido  sin 
accidentes,  y  el  enfermos  no  comete  ninguna  imprudencia  durante  los 
tres  primeros  dias,  no  existen,  salvo  en  rarisimas  escepciones.  Si 
hemos  practicado  la  extraccion  combinada,  es  posible  un  enclava- 
miento  en  los  labios  de  la  herida  de  las  fibras  zonulares  o  de  los  angulos 
del  coloboma,  ocasionandose  retrasos  en  la  cicatriz,  iridociclitis  plas- 
tica  y  glaucoma  secundario.  En  los  casos  de  extracci6n  laboriosa, 
en  los  que  se  ha  pellizcado  el  iris,  puede  sobrevenir  ligera  iritis.  Si 
durante  el  transcurso  de  la  operacion  se  ha  roto  la  capsula,  las  com- 
plicaciones son  analogas  a  las  que  se  producen  operando  por  quisti- 
tomia.  En  los  casos  de  hernia  vitrea,  si  logramos  seccionarla  y 


318  IGNACIO  BARRAQUER 

coaptar  los  labios  de  la  herida  con  la  sutura,  queda  la  pupila  negra, 
central  redonda,  y  como  unica  consecuencia  ligeras  opacidades  del 
vitreo  que  desaparecen  lentamente.  En  los  enfermos  indociles,  que 
se  mueven,  tienen  tos,  propensos  al  vomito  o  que  reciben  algun 
traumatismo,  si  la  operacion  ha  sido  practicada  con  brecha  periferica 
y  sutura  del  colgajo,  la  complicacion  se  limita,  las  mas  de  las  veces,  d 
una  ligera  reabertura  subconjuntival  de  la  herida  y  una  gota  de 
hifema.  Complicacion  que  desaparece  con  24  horas  de  reposo  sin 
ulteriores  consecuencias. 

Del  estudio  atento  de  las  historias  clinicas  de  mis  operados  se 
deduce  que  todos  los  accidentes  operatorios  y  post-operatorios  re- 
conocen  por  origen  una  imprevision,  una  falta  de  tecnica,  6  una  indo- 
cilidad  por  parte  del  enfermo,  y  que  el  maximum  de  garantias  consiste 
en  la  extraccion  simple  con  brecha  periferica,  sutura  conjuntival 
previa  y  paralisis  temporal  del  orbicular. 

La  falta  de  sintomas  reaccionales  debidos  a  la  simplicidad  de  la 
maniobra  quinirgica,  y  d  la  ausencia  de  restos  cristalinianos  en  las 
camaras  del  ojo,  acortan  la  duracion  de  la  convalescencia  y  aseguran 
una  agudeza  visual  normal. 


OPERATION  DE  BARRAQUER 

PROFESSEUR  EMILE  GALLEMAERTS 

Bruxelles 

L'extraction  du  cristallin  dans  sa  capsule  a  ete  a  differentes  epoques 
mise  en  pratique;  ses  avantages  et  ses  inconvenients  ont  ete  sou  vent 
mis  en  discussion;  mais  en  raison  des  difficultes  inherentes  a  son 
execution  sans  que  1'oeil  ait  a  en  souffrir,  elle  a  ete  abandonnee  et 
remise  en  honneur  tour  a  tour.  L'operation  de  Smith  et  celle  de 
Barraquer  viennent  a  nouveau  de  poser  le  probleme  de  1'extraction 
totale. 

J'ai  public  la  relation  de  24  cas  operes  par  la  methode  de  Barraquer; 
de  ces  24  cas,  j  'en  avais  opere  6  avec  succes  sous  la  direction  de  Barra- 
quer; il  est  inutile  d'  insister  sur  la  surete  que  Ton  possede  quand  on 
peut  a  chaque  instant  recourir  aux  conseils  d'un  maitre.  Lorsque  on 
est  livre  a  ses  propres  moyens  on  se  trouve  a  tout  moment  devant 
une  serie  de  difficultes  qu'il  faut  resoudre  sur  le  champ. 

Cette  communication  a  surtout  pour  but  d'exposer  les  accidents  qui 
me  sont  survenus  au  cours  de  46  operations  que  j '  ai  pratiquees ;  leur 
description  permettra  a  ceux  qui  voudraient  essayer  la  methode 
nouvelle  de  les  eviter  et  de  diminuer  le  nombre  de  leurs  insucces.  . 

ERISIPHAQUE 

L'operateur  doit  porter  une  grande  attention  a  la  marche  reguliere 
de  1'appareil.  Lorsque  on  prend  livraison  de  1'appareil,  il  est  prudent 
de  nettoyer  d'abord  le  moteur,  en  y  faisant  passer  un  courant  de 
petrole;  sinon  la  premiere  partie  d'huile  qu'on  y  introduit  revient 
chargee  d'impurete's;  on  peut  clarifier  cette  huile,  en  la  nltrant  sur  du 
noir  animal.  II  est  bon  d'enlever  1'huile  apres  chaque  seance  d'opera- 
tion,  et  de  nettoyer  ensuite  le  moteur  au  petrole. 

L'appareil  porte-ventouse  doit  etre  d'une  proprete  extreme.  ,  On  le 
nettoie  a  Faide  d'un  petit  baton  dont  le  bout  taille"  en  pointe  est 
recouvert  de  gaze.  II  faudra  passer  un  mandrin  dans  les  divers  trous 
et  trajets,  bouches  souvent  par  du  sang  ou  des  debris  organiques  en- 
traines  par  1'aspiration;  il  faudra  nettoyer  de  meme  la  ventouse. 

319 


320  EMILE  GALLEMAERTS 

Au  debut,  pour  m'assurer  du  fonctiormement,  j'approchai  la  ven- 
touse de  Foreille  pour  entendre  le  clapotement  produit  par  la  succion. 
Actuellement  j'ai  etabli  un  systeme  de  controle  qui  me  renseigne  sur  le 
champ  sur  le  fonctionnement  regulier  de  Fappareil.  J'ai  intercale  sur 
la  trajet  du  tube  d'aspiration  un  petit  vacuometre,  a  1'aide  d'un  tube 
en  T.  Lorsqu'on  met  le  moteur  en  marche,  on  voit  rapidement,  au  bout 
de  4  a  5  secondes,  le  vide  atteindre  55  a  60  centimetres;  puis  je  place 
la  ventouse  sur  la  peau  du  bras  ou  sur  la  levre,  et  j'etablis  la  com- 
munication en  pressant  sur  le  bouton  de  1'appareil  porte-ventouse; 
on  voit  d'abord  une  chute  brusque  du  vide  a  '45  centimetres,  puis  une 
remonte  rapide;  on  a  a  peine  le  temps  de  compter  j  usque  4  et  deja  le 
vacuometre  est  revenu  a  60.  L'appareil  est  alors  en  ordre;  pour 
I'emploi  il  suffit  de  steriliser  la  ventouse  dans  la  flamme  d'une  lampe  a 
alcool.  Je  considere  I'emploi  du  vacuometre  non  seulement  comme 
utile,  mais  comme  indispensable;  il  permet  de  se  rendre  compte,  a 
chaque  instant,  avant  et  pendant  1'operation,  de  la  marche  reguliere  de 
1'aspirateur. 

PREPARATION  DE  L'OPERE 

Barraquer  prepare  le  malade  en  vue  de  1'operation  pendant  plusieurs 
jours;  apres  1 'avoir  couche  il  lui  fait  faire  des  mouvements  des  yeux. 
J'ai  trouve*  cette  pratique  inutile,  je  dirai  meme  nuisible.  J'ai  con- 
state que  les  operes  que  Ton  traitait  de  cette  fac.on  pendant  plusieurs 
jours,  arrivaient  a  1'operation  bien  plus  agites  et  anxieux  que  ceux  que 
1'on  se  contentait  simplement  de  coucher  sur  la  table  apres  leur  avoir 
recommande  de  se  tenir  tranquilles  et  de  ne  pas  faire  de  mouvements 
brusques  avec  les  yeux. 

Tous  les  ope"res  sont  examines  preablement  a  la  lampe  a  fente;  on  se 
rend  ainsi  compte  beaucoup  mieux  de  la  forme  de  la  cataracte;  en 
meme  temps  j 'examine  1'etat  de  1'iris.  C'est  ainsi  que  sur  45  cas,  j'ai 
trouve  19  fois  de  la  degenerescence  hyaline  du  bord  pupillaire  avec 
disparition  plus  ou  moins  etendue  de  la  collerette;  deux  fois,  il  y 
avait  en  meme  temps  de  1'atrophie  du  feuillet  posterieur  de  1'iris.  La 
veille  de  1'operation,  on  lave  abondamment  les  yeux,  au  se"rum  sterilise; 
on  s'assure  de  la  permeabilite  des  voies  lacrymales;  on  savonne  le 
bord  des  paupieres  et  on  le  badigeonne  avec  une  solution  de  nitrate 
d'argent  a  3%. 

Une  heure  avant  1'operation,  on  instille  toutes  les  dix  minutes  un 
collyre  a  1'euphtalmine,  a  4%  contenant  quelques  gouttes  de  cocaine 
a  5%,  de  maniere  a  obtenir  une  dilatation  pupillaire  maxima  qui  est 
absolument  indispensable.  Puis  on  met  de  la  cocaine  5%  dix  minutes 


Operation  de  Barraquer  321 

avant  1'operation.  Je  ne  fais  I'injection  &  la  tempe  pour  la  paralysie 
partielle  des  paupieres  que  lorsque  je  me  trouve  en  presence  de  malades 
indociles.  Au  moment  d'operer,  un  aide  retourne  la  paupiere  superi- 
eure,  et  la  saisit  entre  les  mors  d'une  pince,  de  maniere  a  etaler  large- 
ment  le  cul  de  sac  conjonctival;  1'aide  ecarte  en  meme  temps  la  pau- 
piere inferieure;  une  infirmiere  arrose  alors  abondamment  1'oeil  de 
maniere  a  entrainer  toutes  les  mucosites. 

TECHNIQUE  DE  L'OPERATION 

Le  moteur  est  place  sur  un  plateau  rond  et  cale  a  1'aide  d'une  vis; 
ce  plateau  est  adapte  a  une  bague  mobile  sur  une  tige  verticale  portee 
par  un  pied  en  fonte ;  la  bague  porte  le  vacuometre  et  en  meme  temps 
un  petit  plateau  pour  les  instruments.  L'appareil  est  place  a  droite  de 
1'operateur.  Avant  de  commencer,  il  est  prudent  de  controler  une 
derniere  fois  la  marehe  de  Fappareil;  j'insiste  sur  le  fait,  par  ce  qu'il 
m'est  arrive  de  devoir,  apres  1'incision  de  la  cornee,  attendre  pendant 
quelques  minutes  pour  deboucher  la  ventouse.  Pour  ecarter  les  pau- 
pieres je  me  suis  servi  au  debut  d'un  ecarteur  de  Desmares;  actuelle- 
ment  j  'emploie  avec  avantage  un  crochet  a  strabisme  que  Ton  place 
et  retire  plus  facilement. 

L'aide  ecarte  la  paupiere  superieure  a  1'aide  du  crochet  a  strabisme 
tenu  d'une  main;  1'autre  main  ecarte  la  paupiere  inferieure  1'opera- 
teur  fait  son  incision  corneenne  comme  il  a  1'habitude  de  la  faire; 
seulement  le  lambeau  doit  etre  plus  grand,  il  doit  occuper  les  2/5  de  la 
cornee.  L'incision  est  faite  a  Funion  de  la  cornee  et  de  la  sclerotique, 
et  terminee  par  un  lambeau  conjonctival. 

L'incision  faite,  1'on  retire  le  crochet  a  strabisme,  et  je  pratique 
alors  une  petite  iridectomie  soit  totale  soit  peripherique  a  la  maniere 
de  Hess.  Je  maintiens  moi-meme  la  paupiere  superieure  en  la  pressant 
centre  le  rebord  orbitaire  a  1'aide  du  petit  doigt  de  la  main  gauche  qui 
manie  la  pince  ou  le  crochet  de  Tyrrel. 

S'il  y  a  du  sang  dans  la  chambre  anterieure,  je  lave  abondamment 
avec  du  serum  sterilise.  Ensuite  je  replace  moi-meme  le  crochet  a 
strabisme  de  la  main  gauche  et  je  releve  la  paupiere  tout  en  la  tirant 
en  haut.  Je  ne  commande  pas  au  malade  de  regarder,  en  bas  je  lui 
demande  de  se  tenir  tranquille.  A  ce  moment  le  moteur  est  mis  en 
marehe ;  quand  le  vide  atteint  le  degre  voulu  de  55  a  65  centimetres, 
j'introduis  lateralement  la  ventouse,  en  dehors  pour  1'oeil  droit,  en 
dedans  pour  1'oeil  gauche.  La  ventouse  passe  sous  le  bord  pupillaire. 
Apres  1'avoir  delicatement  pose*e  sur  le  cristallin,  on  presse  le  bouton 
21 


322  EMILE  GALLEMAERTS 

pour  e"tablir  la  communication  entre  la  ventouse  et  1'aspirateur.  A  ce 
moment,  le  vacuometre  descend  vers  45c.  pour  remonter  immediate- 
ment  a  son  point  de  depart.  Alors  on  peut  retirer  la  ventouse  en 
faisant  glisser  le  cristallin  sur  la  fossette  patellaire,  tout  en  faisant 
basculer  le  manche  de  1'instrument  en  avant.  Ou  bien  on  fait  exe- 
cuter  au  cristallin  un  cumulet  de  maniere  a  ramener  sa  face  posterieure 
en  avant;  il  faut  pour  cela  faire  basculer  le  manche  en  arriere. 

Le  cristallin  sorti,  on  instille  de  1'eserine  huileuse;  on  attend 
quelques  minutes  avant  de  faire  la  reduction  de  Piris;  j'emploie  pour 
cette  manoeuvre  une  spatule  coudee  a  angle  droit. 

Comme  pansement,  je  place  le  binocle  avec  une  bande,  ou  bien, 
comme  Barraquer,  je  maintiens  les  bourdonnets  d'ouate  a  1'aide  de 
bandelettes  croisees.  Si  Popere"  ne  se  plaint  pas,  j'enleve  le  pansement 
de  1'oeil  non  opere  le  4ieme  jour,  celui  de  1'oeil  opere  au  bout  de  7  a  8 
jours.  Le  pansement  reste  done  en  place  plus  longtemps  que  dans 
1'operation  ordinaire.  J'ai  vu  une  hernie  du  vitre  se  produire  chez  une 
malade  privee  de  pansement  le  6ieme  jour. 

Telle  est  la  marche  d'une  operation  normalement  conduite. 

ACCIDENTS  OPERATOIRES 

Une  plaie  trop  petite  empeche  1'introduction  facile  de  la  ventouse, 
et  surtout  arrete  la  sortie  du  cristallin.  On  doit  agrandir  la  plaie,  en 
sectionnant  un  des  angles  avec  des  ciseaux  droits  a  branches  courtes  et 
fortes. 

Si  le  lambeau  conjonctival  commence  trop  bas,  il  empeche  1'intro- 
duction de  la  ventouse;  cet  accident  m'est  arrive  deux  fois.  Pour 
eviter  cet  inconvenient,  il  faut  changer  le  point  d'introduction,  ou 
meme  faire  sou  lever  le  lambeau  conjonctival  a  1'aide  d'une  pince. 

Le  pincement  de  1'iris  provoque  de  la  douleur,  et  aussi  de  1'hem- 
orrhagie;  on  peut  meme  en  retirant  la  ventouse,  produire  un  decol- 
lement  de  1'iris.  En  cas  de  pincement,  il  faut  lacher  le  bouton  de  pres- 
sion  et  r&ntroduire  la  ventouse. 

L'hemorrhagie  dans  la  chambre  ante"rieure  disparait  tou jours  facile- 
ment  par  lavage;  dans  un  cas  cependant,  il  s'etait  forme  un  grand 
caillot,  que  je  ne  parvins  pas  a  enlever.  Je  me  suis  decide  a  trans- 
former 1'operation  de  Barraquer,  en  une  operation  de  Smith;  en 
pressant  sur  la  partie  inferieure  de  la  cornee  a  1'aide  d'un  crochet  a 
strabisme,  j'ai  pu  faire  sortir  le  cristallin  sans  perte  de  vitre;  la 
vision  de  cet  opere'  fut  de  0.1  avec  +11  dioptrics. 

L'accident  le  plus  frequent  est  celui  qui  provient  d'un  defaut  dans 


Operation  de  Barraquer  323 

Padherence  du  cristallin  a  la  ventouse;  la  ventouse  lache  le  cristallin, 
soit  ail  moment  ou  on  veut  faire  1'extraction,  soit  lorsque  le  cristallin 
est  deja  mis  en  mouvement,  soit  lorsqu'il  se  presente  de"ja  dans  la 
plaie:  un  bruit  de  friture  annonce  1'accident.  II  faut  alors  retirer 
rapidement  la  ventouse.  Dans  un  cas,  le  cristallin  s'est  engage  dans 
le  trou  d'une  iridectomie  periphe'rique ;  avant  de  reintroduire  la  ven- 
touse, j'ai  sectionne  le  bord  pupillaire  qui  avait  ete  conserve.  Si  les 
circonstances  restent  favorables,  on  peut  reintroduire  la  ventouse 
plusieurs  fois;  il  m'est  arrive  de  reussir  a  Ia4ieme  reprise;  mais  il  faut 
naturellement  dans  les  tentatives  repetees,  veiller  a  ne  pas  aspirer  le 
vitre.  Le  cas  suivant  extraordinaire,  merite  d'etre  rapporte.  Je  faisais 
une  troisieme  tentative  d'aspiration  chez  un  de  mes  operes,  quand 
tout  d'un  coup  j'entends  un  bruit  de  succion,  je  vois  1'oeil  s'affaisser 
completement;  malgre  1'enorme  perte  de  vitre  je  me  decide  sur  le 
champ  a  faire  1'extraction  du  cristallin  a Taide  de  1'anse  de  Snellen; 
la  manoeuvre  reussit  mais  Foeil  est  tout  ratatine;  la  cornee  deborde  la 
levre  scleroticale,  en  outre  il  s'est  forme  dans  la  sclerotique  un  pli  que 
je  m'efforce  de  require.  Je  m'attendais  naturellement  a  un  desastre. 
Les  jours  suivants  le  malade  ne  se  plaint  pas;  j'enleve  le  pansement 
le  7ieme  jour.  A  mon  plus  grand  etonnement,  I'oeil  s'est  reconstitute 
completement;  la  plaie  est  fermee;  le  malade  voit.  Actuellement  la 
vision  est  de  0.6  avec  13  dipotries.  De  toutes  les  operations  que  j'ai 
faites,  .c'est  la  plus  extraordinaire. 

Un  autre  accident  consiste  dans  la  rupture  deja  capsule,  trop  faible 
pour  resister  a  la  traction  exercee  par  le  vide;  on  se  trouve  alors  en 
presence  d'une  extraction  avec  discission  que  Ton  termine  suivant  les 
regies  ordinaires. 

La  luxation  du  cristallin  constitue  Paccident  le  plus  grave.  Parfois 
le  cristallin  est  luxe  directement  en  haut;  on  peut  le  faire  glisser  en 
bas  a  1'aide  d'une  spatule  et  puis  tenter  de  nouveau  1'aspiration.  Ou 
bien  il  bascule  en  arriere,  le  vitre  venant  se  placer  au  devant ;  dans  ce 
cas  il  ne  reste  que  la  seule  ressource  de  recourir  a  1'extraction  a  1'aide  de 
1'anse  de  Snellen  ou  de  Taylor.  On  1'introduit  rapidement  derriere 
le  cristallin,  puis  on  reporte  le  manche  en  arriere ;  au  lieu  de  retirer  le 
cristallin  en  1'appliquant  contre  la  cornee,  on  le  fait  glisser  sur  1'anse  a 
1'aide  d'un  crochet  a  strabisme  applique  exterieurement  sur  la  cornee. 
Cette  manoeuvre  est  moins  brutale  et  expose  a  moins  de  perte  de 
vitre. 

L'ecoulement  de  vitre  avant  1'introduction  de  la  ventouse  ne  m'est 
pas  arrive.  Apres.  la  premiere  introduction,  le  corps  vitro"  peut  se 


324  EMILE  GALLEMAERTS 

placer  au  devant  du  cristallin,  sans  qu'il  y  ait  luxation;  dans  ce  cas  il 
faut  faire  1'extraction  par  discission.  A  deux  reprises,  il  m'est  arrive"  le 
singulier  accident  suivant :  Apres  une  premiere  tentative  inutile,  1'iris 
prend  la  forme  d'entonnoir  au  fond  duquel  se  trouve  le  cristallin.  La 
corne'e  bombe'e,  rigide  au  lieu  d'etre  affaissee,  est  se'pare'e  du  cristallin 
par  un  grand  espace;  quand  on  introduit  une  spatule,  la  cornee 
s'affaisse. 

L'ecoulement  du  vitro"  peut  se  produire  apres  la  sortie  du  cristallin. 
Parfois  apres  la  sortie,  le  vitre  se  pr£sente  un  moment  dans  la  plaie, 
puis  rentre  aussitot.  Parfois  au  lieu  de  s'ecouler,  il  vient  former  une 
boule  entre  les  levres  de  la  plaie :  il  vaut  mieux  dans  ce  cas  exciser  la 
hernie  du  vitro"  avec  les  pince-ciseaux.  Si  au  bout  de  quelques  jours  la 
hernie  persiste,  je  n'hesite  pas  a  la  recouvrir  &  1'aide  d'un  lambeau  con- 
jonctival;  dans  deux  cas  trace's  de  la  sorte,  j'ai  obtenu  une  bonne  et 
rapide  fermeture  de  la  plaie. 

SUITES  DE  L'OPERATION 

II  y  a  souvent  de  la  keratite  stride  qui  disparait  assez  rapidement 
sans  laisser  de  traces.  Dans  un  cas  de  keratite  stride,  le  corps  vitro 
etait  venu  s'accoler  a  la  face  posterieure  de  la  corne'e  et  y  determiner 
une  forte  opacite". 

L'enclavement  de  1'iris  dans  Tun  des  angles  de  la  plaie  s'est  produit 
dans  une  demi  douzaine  de  cas.  Dans  7  cas  il  y  a  eu  une  deformation 
de  la  pupille  deViee  ve.rs  le  haut.  Cette  complication  est  moins  grave 
que  dans  1'extraction  avec  discission.  Dans  un  cas  j'ai  eu  apres  une 
extraction  normale,  une  hernie  du  vitre  constatee  le  6  ieme  jour. 

II  est  interessant  d'examiner  au  bout  de  quelque  temps  les  ope"re"s 
a  la  lampe  a  fente.  On  constate  dans  le  champ  pupillaire  que  le  vi- 
tro" tombe  en  avant;  dans  un  cas  opere  sans  iridectomie,  j'ai  trouve 
le  vitro"  sous  forme  de  champignon  pedicule,  faisant  saillie  a  travers 
1'ouverture  pupillaire.  J'ai  obtenu  un  decollement  de  la  re"tine,  con- 
secutif  a  1'operation. 

Barraquer  a  e"crit  qu'il  ne  pouvait  se  former  d'adhe"rence  entre  1'iris  et 
le  vitr6 ;  j'ai  vu  un  cas  ou  il  s'etait  produit  une  adherence  tres  nette 
entre  le  vitro"  et  le  bord  pupillaire;  1'extraction  s'etait  faite  normale- 
ment. 

Dans  deux  cas  ou  j'ai  du  employer  1'anse,  il  s'est  forme  aux  depens 
de  masses  cristallines,  un  amas  de  substance  blanche,  masquant  com- 
pletement  la  pupille ;  dans  un  cas  la  resorption  est  presque  complete ; 
dans  le  second  la  resorption  est  en  train  de  se  faire. 


Operation  de  Barraquer  325 

Si  je  resume  les  cas  voici  les  visions  obtenues: 
Vision  0  dans  deux  cas  d'insucces  complet. 

un  cas  de  choroiidite  maculaire.     (Resultat  operatoire  par- 
fait.) 

2  cas  de  chorioretinite  specifique  ancienne  (idem). 

1  cas  de  decollement  de  la  retine  anterieur  (idem). 
Vision  0.1     6  cas. 

0.2    7  cas. 

0.3     6  cas. 

0.4    5  cas. 

0.5     1  cas. 

0.6    4  cas. 

0.7    4  cas. 
Vision  0.1     a  3  metres  1  cas. 

0.2    a  2  metres  1  cas. 

0.1     a  1  metre  1  cas. 

Le  point  le  plus  delicat  de  1'operation  de  Barraquer,  celui  dont 
depend  le  succes,  est  le  moment  de  la  pression  sur  le  bouton  de  1'ap- 
pareil  porte-ventouse ;  il  suffit  d'un  instant  d'inattention,  lorsqu'on 
fait  la  traction  pour  la  manoeuvre  de  sortie,  pour  que  le  vide  diminue, 
et  que  le  cristallin  retombe.  C'est  pour  moi  le  defaut  de  1'appareil;  le 
vide  ne  devrait  pas  dependre  d'un  mouvement  involontaire;  il  devrait 
rester  permanent  et  ne  pourrait  disparaitre  que  par  une  manoeuvre 
volontaire.  C'est  pour  remedier  a  cet  inconvenient  que  nous  avons 
essaye  de  rendre  le  systeme  d'occlusion  independant  de  la  ventouse. 
A  cet  effet,  la  ventouse  est  place'e  a  1'extremit^  d'un  manche  long  de 
7  centimetres  et  de  7  mill,  de  diametre ;  Pappareil  porte-ventouse  con- 
tenant  les  soupapes  est  intercale  dans  le  trajet  du  tuyau  en  caou- 
tchouc entre  le  vacuo  metre  et  la  ventouse.  La  disposition  est  repre- 
sente  dans  la  photographic  ci-contre  (Fig.  1).  La  ventouse  semanie 
comme  le  manche  d'un  instrument  ordinaire.  Un  aide  presse  sur  le 
bouton  au  commandement  de  Poperateur,  quand  la  ventouse  est  en 
place;  1'aide  signale  le  moment  ou  le  vide  a  de  nouveau  atteint  le 
de"gre"  voulu;  la  manoeuvre  d 'extraction  commence  alors  avec  plus  de 
surete  et  de  chance  de  succes  que  lorsqu'on  se  sert  du  dispositif  de 
Barraquer. 

II  faudrait  probablement  modifier  la  ventouse  aussi,  de  maniere  a 
rendre  plus  intime  1'adherence  du  cristallin.  Quand  cette  derniere 
condition  sera  realised,  je  crois  que  les  chances  d'insucces  seront  re"- 
duites  au  minimum. 


325 


EMILE  GALLEMAERTS 


Y  A-T-IL  UN  VlDE  VlBRATOIRE? 

L'existence  du  vide  vibratoire  produit  par  1'erisiphaque  a  ete  mise  en 
doute;  nous  avons  le  docteur  Kleefeld,  et  moi,  essaye  de  le  mettre 
clairement  en  evidence  et  meme  de  1'inscrire.  Kleefeld  a  d'abord  note 
des  vibrations  en  introduisant  le  tuyau  aspirateur  de  1'erisiphaque 
dans  1'entonnoir  d'un  appareil  de  physique  appele  flamme  sensible. 
Ensuite  nous  avans  eu  recours  a  un  dispositif  imagine  par  le  pro- 


Fig.  1 

fesseur  de  physique  Henriot.  Le  dispositif  employe  consiste  en  une 
capsule  manometrique,  formee  d'une  boite  cylindrique  dont  une  des 
bases  est  plus  depressible  que  1'autre.  Deux  pertuis  y  sont  menage's, 
Tun  pour  faire  1'aspiration,  1'autre  pour  etre  mis  en  rapport  avec  1'ap- 
pareil  porte-ventouse.  Le  controle  du  vide  se  fait  a  Paide  du  vacuo- 
metre.  Un  fil  metallique  est  tendu  a  la  face  exterieure  de  la  capsule, 
et  rattache  aux  deux  extremites  du  diametre  vertical;  ce  fil  soutient 


Operation  de  Barraquer 


327 


une  lamelle  m^tallique  qui  s'appuie  sur 
la  surface  de  la  capsule,  il  porte  un 
petit  miroir  concave.  En  face  de  la 
capsule  on  place  comme  source  lum- 
ineuse  une  ampoule  electrique,  type 
monowatt.  L'image  de  cette  lampe  est 
concentree  sur  une  regie  graduee  en  cel- 
luloi'de ;  on  peut  ainsi  suivre  le  mouve- 
ment  de  la  mouche  lumineuse  le  long  de 
la  graduation.  Au  moment  ou  le  vide 
s'etablit,  on  voit  la  mouche  se  deplacer 
rapidement  sur  Pechelle,  en  meme 
temps  le  filament  devient  flou. ;  il  en 
est  de  meme  lorsque  on  fait  manoeuvrer 
les  soupapes  de  1'appareil  porte-ven- 
touse.  Si  on  remet  le  filament  au  point 
par  interposition  d'une  lentille  conver- 
gentie  entre  le  miroir  et  Fechelle,  on 
constate  la  nettete  absolue  du  filament 
quaiid  le  vide  maximum  a  ete  atteint. 
Get  kppareil  experimental  tout  en  reu- 
nissant  certaines  conditions  de  sensi- 
bilit6  ne  nous  a  pas  permis  d'inscrire 
des  vibrations.  La  deformation  de  la 
paroi  de  la  capsule  sous  Faction  de  la 
pression  atmospherique  diminue  les 
possibilites  d'une  transmission  de  vi- 
brations existant  a  Finterieur  du  sys- 
tems d'aspiration. 

Pour  arriver  a  se  rendre  compte  des 
mouvements  de  Fair  dans  le  tuyau 
d'aspiration,  Kleefeld  a  imagine  le  dis- 
positif  suivant :  dans  un  tube  de  verre 
d'un  calibre  a  peine  superieur  a  la 
section  interieure  de  la  tuyauterie  de 
caoutchouc,  on  suspend  une  feuille 
d'or.  La  minceur,  Fextreme  mallea- 
bilite,  Fabsence  de  vibrations  propres, 
le  poids  negligeable,  font  de  la  feuille 
d'or  un  indicateur  precieux  des  moin- 


328 


EMILE  GALLEMAEBTS 


dres  vibrations  d'un  systeme  gazeux.  On  interpose  cet  indicateur  entre 
l'6risiphaque  et  le  porte-ventouse.  On  place  le  systeme  dans  line 
lanterne  a  projection.  L'ombre  de  la  feuille  d'or  est  recueillie  sur  un 
6cran,  ou  bien  inscrite  sur  une  plaque  photographique.  Quand  on  met 
I'erisiphaque  en  marche,  on  voit  sur  1'ecran,  la  feuille  d'or  animee 
d'un  mouvement  de  vibration  tres  intense,  tandis  qu'elle  se  souleve 
assez  rapidement  dans  la  direction  de  Inspiration.  Au  bout  d'un  cer- 
tain temps  cette  vibration  parait  cesser  et  la  feuille  d'or  ne  presente 
plus  que  quelques  soubresauts;  elle  conserve  cependant  Finclinaison 
qu'elle  avait  acquise  au  d6but  de  1'aspiration. 

Pour  inscrire  les  vibrations,  nous  remplagons  l'e*cran  par  un  chassis 


55  cm.  Hg 


60cm. 


Fig.  3 


65  cm. 


dans  lequel  on  fait  glisser  une  plaque  photographique ;  la  plaque  passe 
en  un  mouvement  re"gulier  et  continu,  devant  une  fente  horizontale. 
Nous  avons  ainsi  obtenu  les  traces  ci-joints  (Figs.  2  et  3),  qui  montrent 
nettement  les  oscillations.  Nous  avons  ainsi  la  preuve  que  l'6risipha- 
que  de  Barraquer  produit  un  vide  oscillant  ou  vibratoire. 

Si  on  peut  affirmer  que  ce  vide  vibratoire  existe,  il  est  plus  difficile 
de  dire  quelle  est  sa  part  d'intervention  dans  le  mecanisme  de  1'extrac- 
tion.  A-t-il  une  action  preponderante?1  On  pourrait  peut-etre  aug- 
menter  1  effet  des  vibrations  en  imprimant  a  un  moment  donne,  des 

1  Peut  Stre  1 'aspiration  agit-elle  en  (informant  la  surface  du  sac  cristallinien. 
La  capsule  du  cristallin  est  attire"e  dans  la  ventouse;  en  m6me  temps  elle  exerce 
une  traction  sur  les  fibres  de  la  zonule  qui  se  tendent  et  fmissent  par  se  rompre. 
L'action  des  oscillations  scrait  ainsi  renforcee. 


Operation  de  Barraquer  329 

oscillations  directement  a  la  ventouse  et  favoriser  les  chances  de 
rupture  de  la  zonule. 

Quoiqu'il  en  soit  1'erisiphaque  de  Barraquer  est  un  instrument  qui 
est  venu  donner  a  1'extraction  totale  de  la  cataracte,  une  vogue  nou- 
velle ;  il  supprime  la  pression  sur  le  corps  vitre  qui  est  si  brutale  dans 
1'operation  de  Smith;  sous  ce  rapport,  reparation  de  Barraquer  sur 
celle  de  Smith;  Si  on  a  des  deboires  dans  un  certain  nombre  de  cas, 
de"boires  inevitables  dans  les  premiers  essais,  du  moins  dans  ceux  qui 
se  terminent  avec  succes,  le  resultat  donne  de  grandes  satisfactions; 
pas  d'irritation,  une  pupille  noire,  une  vision  excellente,  et  surtout  pas 
de  cataracte  secondaire  a  redouter.  Ce  sont  des  avantages  dont  il  ne 
faut  pas  meconnaitre  le  prix. 

Avant  de  pouvoir  se  prononcer  sur  la  valeur  definitive  du  procede, 
il  faudra  que  la  me"thode  soit  largement  raise  en  pratique.  II  en  a  e"te" 
de  meme  de  1'extraction  avec  discission.  Que  1'on  relise  le  nombre 
incalculable  de  travaux  publics  sur  ce  su jet,  les  discussions  dans  les 
congres,  on  verra  qu'il  a  f  allu  des  annees  pour  e"tablir  les  regies  qui  nous 
ont  amenes  a  la  precision  obteniie  par  le  procede  operatoirs  de  la  dis- 
cission. II  en  sera  de  meme  pour  1'extraction  totale  par  1'erisiphaque 
ou  pour  toute  autre  methode  semblable.  II  faut  que  chacun  aborde 
cette  6tude  sans  parti  pris;  en  y  apportant  le  sincerite"  que  Ton  doit 
exiger  dans  toute  recherche  scientifique.  Pour  moi,  malgre  les  insuc- 
ces  que  j'ai  signales,  je  reste  convaincu  que  1'operation  de  Barraquer 
est  appelee  &  un  grand  avenir  et  qu'elle  ne  tardera  pas  a  entrer  dans  la 
pratique  courante. 

DISCUSSION  OF  PAPERS  OF  PROFESSORS  BARRAQUER  AND 

GALLEMAERTS 

DR.  LUCIEN  HOWE  (Buffalo,  N.  Y.):  Although  I  have  not  seen  this  opera- 
tion, the  principle  described  is  not  new.  As  I  understand  it,  some  suction 
must  in  reality  be  made,  otherwise  there  would  be  no  need  of  what  is  prac- 
tically a  suction  pump.  Many  years  ago,  when  Knapp  reported  a  series  of 
extractions,  he  said,  in  substance,  that  while  the  "vis  a  tergo"  principle 
served  our  purpose,  it  would  be  much  better  if  we  could  have  some  way  of 
drawing  out  the  lens  by  a  "vis  a  fronte."  It  then  occurred  naturally  to  me, 
as  probably  to  many  others,  to  employ  some  arrangement  by  which  suction 
could  be  made.  I  tried,  but  failed  at  first,  because  the  suction  sucked  out 
lens  arid  vitreous  also.  Therefore  I  simply  attached  a  small  rubber  bulb 
to  a  short  tube  with  a  minute  elliptical  opening,  as  shown  in  the  accompanying 
illustration.  That  serves  the  purpose  admirably.  But  not  being  one  of 
ardent  advocates  of  extraction  in  the  capsule,  this  suction  bulb  is  used  only 
in  exceptional  cases.  When,  however,  we  reach  the  embarrassing  point  where 


330  IGNACIO  BARRAQUER  AND  EMILE  GALLEMAERTS 

the  lens  appears  and  we  cannot  make  it  come  out  properly,  it  is  of  real  ad- 
vantage to  employ  slight  suction,  applying  the  tube  to  the  edge  of  the  lens 

in  such  a  way  that  it  can  be  tipped  from  side 

to  side. 

I  think  the  older  men  are  rather  inclined  to 

follow  the  advice  of  one  of  our  American  poets, 

who   was    also   a   physician,   and   say   with 

Holmes : 

"Be  not  the  first  by  whom  the  new  is  tried 
Nor  yet  the  last  to  lay  the  old  aside." 

DR.  JOHN  WESTLEY  WRIGHT  (Columbus, 
Ohio):  My  conception  of  the  intracapsular 
operation  for  cataract  was  the  result  of  fortui- 
tous circumstances  in  my  early  experience  in 
the  flap  and  combined  methods  prevalent  at 
that  time,  which  because  of  an  extensive  in- 
cision of  one-half  of  the  corneal  circumference 
and  an  equally  extensive  flap,  resulted  too 
frequently  in  imperfect  coaptation,  a  prolapse 
of  the  iris,  a  drawn-up  or  obliterated  pupil,  and  more  or  less  corneal  opacity. 
To  avoid  such  discouraging  conditions  I  conceived  an  incision  much  smaller, 
less  liable  to  gap,  and  of  such  dimensions  as  to  permit  the  ready  delivery 
of  the  lens. 

Briefly,  the  incision  is  made  entirely  within  the  cornea,  the  puncture  and 
counterpuncture  being  one-third  down  the  corneal  circumference,  at  the 
sclerocorneal  junction,  and  completed  at  a  point  2  mm.  within  its  upper 
border.  With  this  incision  I  discovered  that  pressure  upon  its  upper  segment, 
in  addition  to  making  the  opening  for  the  delivery  of  the  lens  much  larger 
than  in  the  usual  methods,  caused  a  detachment  of  the  lens  from  the  annular 
ligament  at  its  upper  portion,  when  with  careful  pressure  it  is  stripped  out 
from  the  surrounding  attachments  and  its  delivery  in  capsule  was  readily 
affected.  Pressure  thus  made  causes  a  displacement  of  the  vitreous  in  such 
manner  that  there  is  a  tendency  for  it  to  seek  a  point  of  least  resistance,  thus 
forcing  the  lens  toward  the  open  gap  caused  by  the  incision. 

After  considerable  experience  with  the  technique  and  realizing  its  impor- 
tance, a  description  of  the  operation  was  published  in  the  Columbus  Medical 
Journal,  October,  1884.  Since  its  conception  I  have  practised  this  technique 
with  general  satisfaction  during  my  professional  career. 

The  pupil,  as  a  rule,  dilates  widely  under  the  effects  of  a  mydriatic  and  no 
injury  to  the  iris  results.  For  this  reason  I  rarely  find  it  necessary  to  make 
an  iridectomy.  The  lens,  therefore,  with  gentle  pressure,  will  pass  through 
the  pupillary  space  without  bruising  or  lacerating  the  pupillary  border.  I 
have  knowledge  of  cases  of  dislocated  lens  where,  without  any  effort  whatever 
on  the  part  of  the  patient,  it  passed  readily  from  the  posterior  chamber  to 
that  of  the  anterior,  and  back  again  in  the  absence  of  the  effects  of  a  mydriatic. 


Operation  de  Barraquer  331 

I  have  the  history  of  a  case  where  the  transition  was  readily  effected  at  the 
pleasure  of  the  patient  by  certain  movements  of  his  head. 

If  the  pupil  does  not  dilate  well,  it  is  useless  to  attempt  to  force  the  lens 
through.  This  applies  whether  within  its  capsule  or  in  capsulotomy.  Then 
I  make  a  small  iridectomy,  or  otherwise  an  iridotomy,  by  slitting  the  iris 
slightly  from  the  center  of  its  superior  border  toward  its  periphery.  My 
experience  is  that  a  small  iridectomy  or  an  iridotomy,  as  indicated,  will 
facilitate  the  passage  of  the  lens  as  efficiently  as  a  large  one. 

The  posterior  surface  of  the  lens  lying  as  it  does  against  the  vitreous,  it  is 
not  unusual  for  adhesions  to  occur  between  their  supporting  membranes; 
this,  often  at  the  hyaloid  fossa,  although  they  may  occur  at  other  points, 
when  the  attempted  removal  of  the  lens  in  capsule  is  liable  to  rupture  the 
hyaloid  membrane,  with  more  or  less  loss  of  vitreous,  or,  on  the  other  hand, 
should  a  rupture  of  the  lens-capsule  occur,  fragments  of  it  will  remain  adherent 
to  the  hyaloid  membrane,  and  interfere  with  vision  to  a  greater  or  less  ex- 
tent. In  such  cases  capsulotomy  has  no  advantage  over  the  intracapsular, 
inasmuch  as  the  remaining  capsule  interferes  with  the  visual  acuity  in  either 
method.  These  are  conditions  that  cannot  be  determined  prior  to  operation. 

There  are  cases  where  the  lens  cannot  be  delivered  within  its  capsule 
without  the  risk  of  serious  injury  or  loss  of  the  eye,  generally  for  the  reason 
that  it  is  so  firmly  attached  to  its  supports.  This  condition  cannot  be  defi- 
nitely diagnosed  before  an  attempt  to  dislocate  has  been  made.  My  experience 
has  taught  me  about  how  much  pressure  should  be  made  with  safety,  and  I 
do  not  usually  go  beyond  that  point.  If  the  lens  does  not  readily  become 
detached  from  its  moorings,  then  I  do  capsulotomy,  because  in  this  event 
I  consider  it  the  safer  operation.  I  have  succeeded  in  dislocating  the  lens 
in  some  instances  without  difficulty  where  there  had  been  considerable  iritic 
adhesions. 

The  point  upon  which  pressure  is  made  is  an  important  matter.  It  should 
be  made  upon  the  center  of  the  upper  segment  of  the  cornea,  near  the  incision, 
and  the  counterpressure,  simply  enough  to  steady  the  eye,  on  the  opposite 
side  of  the  cornea.  When  applied  near  its  center,  it  causes  contraction  of  the 
opening  and  impedes  the  delivery  of  the  lens.  Besides,  it  frequently  causes 
buckling  or  kinking  and  occasionally  leaves  slight  opaque  streaks  in  the 
cornea.  This  is  entirely  avoided  with  the  pressure  above  the  incision. 

DR.  JOHN  0.  MCREYNOLDS  (Dallas,  Texas) :  I  am  fully  conscious  of  my 
inability  to  present  a  comprehensive  analysis  of  the  paper  of  Prof.  Barraquer, 
and  I  can  only  hope  to  offer  a  few  conclusions  from  my  observation  of  his 
work  in  Barcelona,  in  New  York,  Boston,  Philadelphia  and  Richmond, 
together  with  some  personal  experience  with  his  method  during  the  past  year. 

The  immediate  results  and  the  impressions  produced  upon  the  profession 
have  varied  exceedingly  in  different  cities.  In  Barcelona,  and  indeed  through- 
out Spain,  the  procedure  has  met  with  a  most  enthusiastic  endorsement.  In 
New  York  and  Boston  the  results  were  not  up  to  the  standard,  while  in 
Philadelphia  and  Richmond  the  operations  were  performed  with  practically 
uniform  success.  In  Richmond,  14  operations  were  made  in  one  day,  and  in 
only  one  case  was  there  any  rupture  of  the  capsule  with  a  tiny  bead  of  vitreous 


332  IGNACIO  BARRAQUER  AND  EMILE  GALLEMAERTS 

lost.  In  Philadelphia  there  were  9  extractions,  with  no  vitreous  lost,  in  the 
Wills  Hospital,  the  Jefferson  Hospital,  and  the  Polyclinic  Hospital. 

In  Boston  there  were  5  operations  made  at  the  Massachusetts  Eye  Infirm- 
ary on  the  first  day,  with  3  cases  of  ruptured  capsule,  in  two  of  which  there 
was  also  some  loss  of  vitreous.  The  rupture  of  the  capsules  in  these  cases 
was  evidently  due  in  large  measure  to  the  fact  that  the  current  was  much  too 
strong.  This  difficulty  was  remedied  on  the  second  day,  when  2  extractions 
were  made  without  accident  of  any  kind. 

In  New  York,  2  extractions  were  made  at  the  Knapp  Memorial  Hospital, 
without  accident;  1  at  the  Manhattan  Eye  Hospital,  without  accident;  3  at 
McLean's  Hospital,  2  of  which  were  correct,  and  one  had  expulsive  hemorrhage 
immediately  following  the  incision  before  any  effort  at  extraction  was  made. 
Seven  operations  were  made  at  the  New  York  Eye  &  Ear  Infirmary,  with  3 
capsules  ruptured,  including  2  cases  of  vitreous  loss. 

In  the  four  American  cities  there  were  43  extractions  with  5  cases  of  slight 
vitreous  loss  and  6  cases  of  ruptured  capsule,  while  in  the  last  23  cases  there 
was  only  one  case  of  a  tiny  bead  of  vitreous  loss.  In  the  last  series  of  23 
cases  Prof.  Barraquer  had  the  same  assistant,  Dr.  Poyales,  of  Madrid,  who 
employed  regularly  lid  retraction  instead  of  the  speculum,  and  the  result 
was  approximately  4  per  cent,  of  vitreous  loss. 

Conclusions. — 1.  In  the  hands  of  an  experienced  and  skilful  operator  the 
method  can  be  developed  to  a  point  where  vitreous  loss  will  become  an 
unimportant  factor. 

2.  An  uncomplicated  rupture  of  the  capsule  reduces  the  operation  essen- 
tially to  a  capsulotomy  operation. 

3.  There  is  no  increase  in  the  hazard  of  choroidal  hemorrhage. 

4.  With  a  peripheral  buttonhole  iridectomy,  which  is  regularly  employed 
when  possible,  there  should  remain  a  permanently  mobile  pupil  without  any 
incarceration  of  the  iris. 

5.  With  a  conjunctival  flap  adequately  held  in  position  with  sutures, 
according  to  Prof.  Barraquer's  method,  the  healing  process  should  be  suffi- 
ciently complete  after  one  week  to  permit  the  patient  to  leave  the  hospital, 
provided  reasonable  supervision  is  maintained. 

6.  The  danger  of  infection  and  postoperative  inflammation  of  all  kinds 
should  be  reduced  to  the  minimum. 

7.  Much  can  be  accomplished  by  a  critical  study  of  the  intimate  structure 
of  each  lens  to  be  operated,  so  that  the  form  of  operation  may  be  modified 
to  meet  the  requirements  of  each  individual  case. 

8.  The  method  should  not  be  undertaken  without  previous  abundant 
experience  with  the  older  and  more  established  measures  of  dealing  with  all 
forms  of  cataract,  because  it  is  more  difficult  of  execution  and  developments 
may  occur  which  only  experienced  hands  can  safely  control. 

9.  It  has  a  definite  place  in  ophthalmic  surgery  as  the  ideal  to  be  attained 
through  unremitting  diligence,  experience  and  care. 

DR.  LODIS  D.  GREEN  (San  Francisco,  Cal.) :  Dr.  Barraquer  deserves  great 
credit  for  reviving  the  suction  operation  by  putting  it  on  a  firm  basis,  thereby 
placing  the  intracapsular  operation  many  steps  forward.  Ophthalmologists 


Operation  de  Barraquer  333 

who  have  mastered  the  intracapsular  operation  and  performed  it  consistently 
by  one  of  the  two  or  three  methods  over  a  period  of  years,  commend  it  highly. 
But  even  for  the  most  skilful,  there  was  much  that  was  left  to  be  desired. 
By  the  forceps  method,  too  many  capsules  were  ruptured  so  that  one  suc- 
ceeded in  doing  the  intracapsular  operation  in  only  a  small  proportion  of 
cases.  The  Smith-Indian  method  requires  a  high  degree  of  skill,  only 
acquired  after  a  great  deal  of  practice  on  a  large  number  of  cases.  The  Bar- 
raquer method  requires  highly  developed  apparatus  and  skill  in  its  use,  and 
even  then  the  considerable  traction  necessary  in  certain  cases  with  tough 
suspensory  ligaments  may  result  in  a  detachment  of  the  choroid  or  retina; 
or  if  the  capsule  breaks,  vitreous  is  liable  to  be  drawn  into  the  tube. 

It  is  only  natural  that  every  surgeon  should  prefer  to  use  the  instruments 
with  which  he  obtains  the  best  results,  and  in  the  hands  of  Dr.  Barraquer  his 
apparatus  undoubtedly  does  all  that  one  could  desire.  In  our  hands,  however, 
we  find  it  has  certain  mechanical  inconveniences  that  interfere  somewhat 
with  the  delicacy  of  manipulation.  We  have  accordingly  modified  it  so  that 
the  valve  is  controlled  by  the  foot,  permitting  the  use  of  a  very  light  cannula 
that  is  held  in  the  hand,  as  delicately  as  a  cataract  knife,  thus  relieving  the 
fingers  of  any  cramped  position. 

According  to  the  manner  in  which  cataracts  are  removed,  operations  may 
be  classified  as  extractions  or  expressions.  The  classical  capsulotomy  and 
the  Smith-Indian  operation  are  expression  operations.  The  Hulen  or 
Barraquer  vacuum  and  Stanculeanu  or  Knapp  forceps  methods  are  extraction 
operations.  We  have  gradually  evolved  a  technique  which  is  a  combination 
of  expression  and  extraction,  and  from  an  experience  of  over  100  cases  that 
we  have  operated  by  this  procedure,  we  believe  it  minimizes,  to  a  great  extent, 
the  dangers  in  either  the  Smith-Indian  operation  or  the  vacuum  operation  as 
advocated  by  Dr.  Barraquer.  This  we  have  described  elsewhere. 

Briefly,  the  method  consists  of  making  a  full  half  section  of  the  cornea 
with  a  conjunctival  flap.  The  flap  is  grasped  and  cornea  raised  with  a 
special  delivery  forceps  which  also  act  as  a  delivery  hook,  and  are  held  in  the 
left  hand,  and  the  cannula  held  in  the  right  hand  is  introduced  and  lightly 
placed  upon  the  cataract.  The  foot  valve  is  now  engaged  and  a  few  seconds 
allowed  for  the  spoon  to  become  firmly  attached  to  the  anterior  capsule  and 
lens;  the  cannula  is  gently  raised  so  that  the  upper  border  of  the  cataract  is 
tilted  forward  into  the  wound,  at  the  same  time  drawing  the  cataract  out  of 
the  eye.  At  the  moment  when  rotation  for  the  delivery  of  the  lens  starts, 
the  left  hand  releases  the  conjunctiva  and  the  forceps  which  held  it  are 
shifted  to  the  lower  part  of  the  eye  near  the  limbus,  and  by  gentle  pressure 
assists  in  delivering  the  lens.  We  thus  attain  an  expression-extraction  with 
a  division  of  the  forces  in  each  and  with  less  trauma  to  the  eye  than  would 
occur  if  either  procedure  were  used  alone. 

COL.  R.  H.  ELLIOT  (London,  England) :  I  had  not  wished  to  speak  to-day, 
but  several  of  my  American  friends  have  asked  me  to  do  so  on  the  strength  of 
my  having  had  some  cataract  practice  in  the  East.  I  am  conscious  on  this 
and  similar  occasions  of  the  warning  uttered  by  Gamaliel  before  the  San- 


334  IGNACIO  BARRAQUER  AND  EMILE  GALLEMAERTS 

hedrin,  if  I  may  change  one  word,  "Lest  by  any  means  we  may  be  found  to 
fight  against  the  truth." 

I  want  first  of  all  to  differ  with  Dr.  Barraquer  most  respectfully  in  the 
analogy  he  has  more  than  once  used  between  the  capsule  laceration  operation 
and  the  removal  of  cysts  from  the  abdomen.  I  respectfully  submit,  that 
there  is  no  such  analogy.  The  irritating  contents  of  such  cysts  and  the 
nature  of  their  walls,  and  the  fact  that  they  will  fill  or  grow  again  if  not  com- 
pletely removed,  put  them  in  an  entirely  different  class  from  the  lens  inside 
its  capsule.  I  emphasize  this  because  many  of  us  with  large  experience  in 
cataract  and  the  capsule  laceration  operation  can  confidently  rely  upon  get- 
ting from  90  per  cent,  to  96  per  cent,  of  good  results  from  that  operation. 

But  the  side  of  the  question  that  I  want  to  bring  before  you  today — please 
understand  that  I  am  not  fighting  against  this  operation,  but  I  do  want  you 
to  think  squarely  about  it — is  related  to  what  is  often  called  the  "diaphragm 
of  the  eye,"  that  is,  the  ciliary  body  with  the  suspensory  ligaments  and 
capsule.  This  diaphragm  is  a  great  protection  to  the  eye,  both  from  the 
mechanical  escape  of  vitreous,  and  also  from  infection.  It  powerfully 
strengthens  the  anterior  hyaloid  membrane.  That  is  a  matter  on  which 
any  man  with  large  cataract  experience  can  have  no  question  in  his  mind.  I 
look  upon — and  always  will  look  upon — the  integrity  of  the  vitreous  at  the 
close  of  a  cataract  operation  as  a  very  great  asset.  It  is  not  merely  that  in 
these  cases  you  are  apt  to  get  an  escape  of  vitreous,  but  that  both  in  the 
Smith  operation  and  I  believe  also  in  Dr.  Barraquer's  operation,  there  is  a 
tendency  to  a  damage  of  the  upper  part  of  the  hyaloid  body  leading  to  a 
definite  tendency  to  herniation  of  that  part.  That  was  observed  by  Col. 
Kirkpatrick  working  with  the  Smith  operation  in  Madras.  It  has  been 
observed  by  Dr.  Wright  working  with  the  Barraquer  operation.  Within  the 
last  few  days  an  exponent  of  the  Barraquer  operation  with  whom  I  raised 
the  question  was  good  enough  to  tell  me  that  he  had  observed  such  a  tendency 
to  herniation  with  the  Gullstrand  slit  lamp.  I  do  not  think  you  can  look 
upon  any  operation  that  weakens  the  upper  part  of  the  hyaloid  and  tends  to 
herniation,  and  to  impaction  of  that  body  in  your  wound,  without  some 
apprehension. 

I  hold  that  the  sound  thing  for  the  younger  operators  to  do  is  to  first  of  all 
select  a  safe  operation.  Then  when  they  have  acquired  manipulation 
facility,  when  they  have  learned  all  that  the  old  operation  has  to  teach,  they 
can  make  up  their  minds  for  themselves  whether  they  ought  or  ought  not  to 
undertake  such  a  procedure  as  this.  I  can  only  say,  that  if  in  the  course  of 
years  I  have  a  cataract  to  be  removed,  I  shall  go  to  a  surgeon  who  will  do  a 
preliminary  iridectomy,  who  will  lacerate  the  capsule,  and  who  will  subse- 
quently do  a  discission.  I  admit  you  can  get  very  beautiful  results  with  the 
Barraquer  operation,  but  if  today  you  were  having  the  two — the  old  and  the 
new  procedures — presented  to  you  for  the  first  time,  with  all  that  can  be 
said  for  and  against  both  of  them,  I  think  you  would  pause  before  you  took 
up  the  intracapsular  operation.  Judge  the  method  logically,  look  at  it  in 
the  large,  and  make  up  your  mind.  If  you  are  going  to  do  it,  watch  your 
records  very  carefully  and  do  not  forget  to  look  for  impaction  of  the  hyaloid 
and  for  disturbance  of  the  transparency  of  the  hyaloid  body. 


Operation  de  Barraquer  335 

PROF.  F.  DE  LAPERSONNE  (Paris,  France) :  En  attendant  que  le  traitement 
medical,  que  les  scrums  et  vaccins  nous  permettent  de  preVenir  ou  de  gue>ir 
la  cataracte,  l'ide"al  ope"ratoire  est  de  faire  1'extraction  dans  la  capsule.  Le 
proce'de'  de  M.  Barraquer  marque  un  grand  progres,  mais  ce  n'est  pas  une 
operation  de  tout  repos.  Les  perfectionnements  successifs  et  les  si  justes 
observations  de  mon  ami  le  Professeur  Gallemaerts,  en  sont  les  meilleures 
preuves. 

Trois  facteurs  principaux  interviennent  (1)  l'ope"rateur;  tout  le  monde  n'a 
pas  la  grande habilite"  de  M.  Barraquer  pour  cette  operation:  je  ne conseillerais 
jamais  a  un  jeune  oculiste  de  faire  sa  premiere  cataracte  par  ce  proce'de: 
meme  pour  un  oculiste  exerc.e',  il  faut  un  stage,  qui  se  fait  aux  depens  du 
malade;  en  plus  le  diagnostic  des  indications  ope"ratoires,  le  calcul  exact,  fait 
a  1'avance,  de  la  resistance  de  la  zonule  me  paraissent  tres  difficiles.  (2)  il 
faut  avoir  un  aide  tres  sur  pour  eViter  toute  pression  (3)  il  faut  enfin  que 
I'instrument  soit  encore  perfectionne'. 

DR.  LLOYD  MILLS  (Los  Angeles,  Cal.) :  When  Prof.  Barraquer  published 
his  first  paper  in  the  Siglo  Medico,  I  read  his  work  with  the  conviction  that 
it  promised  to  be  an  improvement  upon  the  Smith  intracapsular  operation 
which  I  was  then  using  in  selected  cases  with  normally  variable  success.  My 
attempts  to  get  in  touch  with  Prof.  Barraquer  failed,  and,  without  knowing 
the  detail  of  his  instrumentarium,  I  took  up  the  problem  by  attempting  the 
vacuum  extraction  of  kittens'  lenses,  using  an  aluminum-bodied  erisphake 
with  an  air  vent  in  the  side.  This  vent  was  so  much  larger  than  the  tube 
which  carried  air  to  the  suction  cup,  that  the  cup  could  be  applied  to  the  lens 
with  the  suction  already  active  and  yet  without  engagement  between  cup 
and  lens,  until  the  side  vent  was  closed  by  my  finger,  when  the  lens  was 
drawn  at  once  into  the  cup.  As  a  source  of  negative  pressure  I  used  succes- 
sively water  suction,  the  electric  vacuum  apparatus  used  for  ridding  the 
throat  of  blood  in  tonsil  work,  and  finally  connected  our  operating  room 
directly  with  the  great  steam  vacuum  exhaust  of  the  engine-room,  capable  of 
developing  a  vacuum  of  18  inches,  which,  of  course,  was  far  in  excess  of  any 
practical  needs. 

The  first  lesson  learned  was  that  the  lens  slipped  away  from  the  cup  with 
too  little  vacuum;  the  second  was  that  too  sharp  suction  ruptured  the  capsule; 
the  third  was  that  with  strong  suction  applied  directly  to  the  central  part  of 
the  lens  and  using  a  pull  straightforward  the  lens  could  be  extracted  in  capsule, 
but  practically  always  with  the  entire  vitreous  body  attached.  Only  by 
rocking  the  lens  with  some  vigor,  not  radially,  as  in  turning  a  wheel,  but  in 
the  anteroposterior  plane,  could  an  uncomplicated  delivery  of  a  lens  in  its 
capsule  be  obtained.  A  study  of  this  method  led  me  to  believe  that  the 
delivery  of  lens,  with  vitreous  attached,  came  from  the  lack  of  entrance  of 
aqueous  or  air  into  the  patellar  fossa,  for,  when  this  was  accomplished  by 
the  simple  gentle  insertion  of  a  narrow  grooved  spatula  behind  the  lens  with- 
out rupturing  the  hyaloid,  and  with  atmospheric  pressure  behind  the  lens 
equal  to  that  in  front  of  it,  normal  intracapsular  extraction  became  the  rule 
and  not  the  rarity.  May  I  suggest  that  possibly  the  entrance  of  fluid  or  air 


336  IGNACIO  BARRAQUER  AND  EMILE  GALLEMAERTS 

into  this  situation  is  an  additional  and  important  accomplishment  of  vibra- 
tion? 

In  the  light  of  our  constant  experiences  with  the  rise  and  fall  of  surgical 
innovations  in  general  I  feel  that  any  criticism,  and  especially  that  any 
exaggerated  approval  of  Barraquer's  method,  should  be  withheld  until  it 
has  been  tested  analytically  by  competent  men  and  along  the  exact  lines 
which  the  master  himself  has  so  painstakingly  worked  out  over  so  many 
years.  It  seems  to  me  to  be  the  height  of  presumption,  and  our  medical 
editors  are  partly  responsible  for  this,  that  men  should  be  permitted  to  rush 
into  print  after  a  few  performances  of  a  surgical  novelty  and  then  advise 
extreme  modifications  of  a  method  whose  exacting  details  as  a  rule  they  have 
never  fundamentally  acquired.  We  saw  the  evils  of  this  on  the  Pacific  coast 
in  the  propaganda  for  another  form  of  cataract  operation  now  quietly  sinking 
to  its  natural  surgical  level,  when  the  entire  profession  of  that  coast,  and 
indirectly  many  of  our  patients,  were  so  circularized  as  to  the  easy  adapta- 
bility of  this  method  to  all  kinds  and  conditions  of  cataract  that  those  who 
did  not  acquire  this  technique  were  at  times  stigmatized  as  laggards,  if  not 
actually  considered  to  be  to  some  extent  incompetent.  The  constancy  with 
which  any  surgical  method  gives  success  to  the  average  qualified  operator 
is  its  real  measure  of  merit,  and  it  is  sincerely  to  be  hoped  that  the  develop- 
ment of  Prof.  Barraquer's  brilliant  operation  in  America,  if  it  is  to  develop 
here,  will  be  done  in  that  orderly  and  decent  fashion  which  the  scientific 
attitude  of  mind  properly  demands. 

DR.  Jos.  A.  WHITE  (Richmond,  Va.) :  In  a  rather  long  professional  career 
I  have  had  some  little  experience  with  cataract,  extraction,  and  have  become 
wedded  to  a  capsulotomy  operation  with  an  iridectomy,  preferably  pre- 
liminary, if  I  can  get  my  patient's  consent.  This  has  been  reasonably  suc- 
cessful with  me  in  not  a  large  series  of  cataract  extractions,  but  something 
over  1500,  which  is  enough  to  judge  of  results,  and  I  believe  that  it  offers  more 
chances  of  restoring  sight  than  any  of  the  more  recently  suggested  operations. 
There  is  no  question  as  to  the  fact  that  the  intracapsular  method  has  come  to 
stay,  but  I  have  been  loath  to  attempt  it.  The  first  time  that  I  saw  the 
Smith-Indian  operation  there  were  two  cases.  The  pressure  applied  was  so 
great  that  expression  of  the  lens  was  followed  by  considerable  loss  of  vitreous, 
which  is  not  to  be  regarded  lightly.  This  operation,  however,  is  reported 
as  very  successful  in  the  hands  of  those  who  have  had  a  large  experience  with 
it.  Many  modifications  of  the  intracapsular  operation  have  been  suggested 
to  diminish  pressure  and  lessen  traumatism,  and  as  they  come  more  to  what 
I  consider  the  safety  line  it  is  possible  that  I  may  undertake  the  procedure. 

Recently  I  saw  Prof.  Barraquer  do  his  operation  under  favorable  circum- 
stances. I  was  fortunate,  with  the  help  of  my  colleagues,  to  offer  him  18 
cases  of  cataract.  Owing  to  a  little  secretion  in  the  eye  of  two  cases,  a  slight 
dislocation  of  the  lens  in  one,  and  not  sufficient  light  projection  in  the  field  of 
another,  Prof.  Barraquer  rejected  four  and  operated  on  the  balance.  Of  these 
operations  he  had  two  ruptured  capsules,  but  he  removed  the  capsule  ap- 
parently completely.  There  was  only  one  case  where  a  little  vitreous  pre- 
sented at  the  end  of  the  operation.  Later  I  returned  to  the  hospital,  and  none 


Operation  de  Barraquer  337 

of  the  patients  had  the  slightest  discomfort  from  the  time  of  the  operation, 
except  one,  and  all  seemed  to  be  doing  well.  Notwithstanding  the  brilliant 
operations  that  I  saw  done  by  the  intracapsular  methods,  if  I  had  a  cataract 
I  would  have  a  preliminary  iridectomy  done,  the  lens  extracted  after  capsulot- 
omy,  and  take  the  chance  of  capsular  or  after-cataract.  I  am  satisfied  that 
the  old  operation  will  hold  its  own  among  us  for  the  reason  that  the  intra- 
capsular method  is  not  suited  to  certain  forms  and  to  certain  ages. 

MR.  J.  GRAY  CLEGG  (Manchester,  England):  I  have  never  done  the 
operation,  but  I  have  seen  friends  of  mine  do  it  in  London.  When  all  is  well, 
undoubtedly  it  is  an  ideal  operation.  What  I  am  particularly  interested  in  is 
the  after-results,  and  I  wish  therefore  to  ask  Prof.  Barraquer  as  to  the  length 
of  time  of  recovery  and  what  post-operative  complications  occur;  whether  he 
often  finds  detachment  of  the  choroid  and  other  intra-ocular  conditions  which 
detract  from  the  final  results.  These,  it  appears  to  me,  are  points  of  great 
interest,  quite  apart  from  the  question  of  the  operation  itself. 

DR.  S.  GEMBLATH  (Paris,  France):  Dans  une  operation  de  cataracte,  le 
but  primordial,  est  1' amelioration  de  la  vue  du  malade.  Monsieur  Barraquer 
ne  nous  donne  aucun  detail  sur  le  resultat  fonctionnel  de  1'oeil  op6re.  A 
cause  de  la  manoeuvre  op6ratoire  assez  traumatisante,  on  peut  craindre  des 
iridocyclites  traumatiques  plus  ou  moins  tardives. 

D'autre  part,  la  large  incision  corne'enne  ne"cessaire  pour  permettre  la 
sortie  a  la  fois  du  cristallin  et  de  la  canule,  doit  n6cessairement,  il  me  semble, 
donner  lieu  a  un  astigmatisme  plus  fort  que  celui  des  m6thodes  usuelles. 

DR.  W.  A.  FISHER  (Chicago,  111.) :  The  first  paragraph  of  Prof.  Barraquer's 
paper  states  that  the  simple  total  extraction  is  the  only  rational  method  of 
operating  for  cataract,  and  his  conclusions  state  among  other  things  that  loss 
of  vitreous  is  rare  with  paralysis  of  the  orbicular,  and  that  it  occurs  only 
when  the  operator  uses  undue  pressure  on  the  globe  or  the  patient  contracts 
his  orbital  muscle. 

If  his  conclusion  is  well  founded,  and  I  believe  it  is,  then  the  first  paragraph 
of  his  paper  must  be  true — that  the  simple  total  extraction  is  the  only  rational 
method  of  operating  for  cataract.  I  believe  Prof.  Barraquer  has  given  us  a 
method  of  removing  senile  cataracts  that  has  come  to  stay. 

In  his  hands  it  appears  to  be  perfect,  but  I  do  not  believe  experienced 
operators  will  encounter  more  difficulties  by  this  method  than  by  other 
methods.  Prof.  Barraquer's  personal  skill  makes  his  operation  appear 
quite  simple,  but  such  is  not  the  case,  and  the  same  can  be  said  of  all  methods. 

Recently  I  had  the  pleasure  of  seeing  Prof.  Barraquer  operate  upon  nine 
cases  in  Philadelphia,  and  fourteen  in  Richmond,  Virginia.  There  was 
not  a  trace  of  vitreous  loss  in  Philadelphia,  and  in  only  one  case  was  there  a 
loss  of  vitreous  in  Richmond,  and  in  that  one  only  a  drop.  But  I  do  not 
believe  his  operation  will  supplant  all  other  methods.  Twenty-three  opera- 
tions performed  among  strange  surroundings  by  any  method  with  only  one 
vitreous  loss  and  that  one  only  a  drop,  with  a  prospect  of  little  if  any  post- 
operative inflammation,  no  after-cataracts  and  good  vision  in  all  of  them, 
with  the  pupils  all  round  and  looking  normal,  is  more  than  most  operators 
22 


338  IGNACIO  BARRAQUER  AND  EMILE  GALLEMAERTS 

expect.  Prof.  Barraquer  has  achieved  the  above  results  in  twentj'-four 
consecutive  operations,  and  I  feel,  as  I  believe  most  of  you  do,  that  he  should 
be  congratulated  and  encouraged,  and  I  am  sure  the  profession  will  be  bene- 
fited by  his  coming. 

PROP.  IGNACIO  BARRAQUER  (closing) :  Yo  doy  las  gracias  a  los  distinguidos 
oftalmologos  que  me  han  permitido  verificar  tan  gran  numero  de  operaciones 
en  sus  clinicas  y  a  los  que  han  tornado  parte  en  esta  discusion,  aunque  siento 
no  tener  tiempo  para  ser  tan  extenso  como  desearia  y  solo  me  limitare  a 
esclarecer  algunos  conceptos  sobre  mi  operacion : 

1.  No  debe  llamarse  operacion  de  la  catarata  por  succion  toda  vez  que  la 
ventosa  no  aspira  nada  del  ojo;  unicamente  coje  el  cristalino  por  su  cara 
anterior. 

2.  No  hay  posibilidad  de  perdida  de  vitreo  si  no  se  practican  presiones, 
aun  las  mas  pequenas,  sobre  el  ojo;  toda  perdida  de  vitreo  es  un  defecto  de 
tecnica  o  de  preparacion. 

3.  No  se  producen  desprendimientos  ni  de  la  coroides  ni  de  la  retina  ya 
que  el  vacio  vibratorio  rompe  las  fibras  de  la  zonula  junto  al  cristalino,  sin 
que  experimenten  ninguna  traccion  en  su  insercion  perif erica. 

4.  Regulando  convenientemente  la   intensidad   del   vacio,   solamente  se 
rompen  las  capsulas  en  un  minimum  despreciable  de  casos. 

5.  El  Erisifaco  es  un  instrumento  delicado  y  debe  cuidarse  y  probarse 
cada  vez,  como  hacemos  para  con  el  cuchillo  de  Graeffe. 

6.  La  tecnica  de  la  operacion  no  es  dificil  tal  como  yo  la  practico ;  cualquier 
operador  que  sepa  tallar  correctamente  un  colgajo  puede  hacerlo,   pues 
considero  mas  dificil  la  talla  de  colgajos  correctos  que  la  maniobra  de  extrac- 
cion  con  el  Erisifaco. 

7.  Es  de  suma  importancia  el  estudio  previo,  seleccion  y  preparacion 
minuciosa  de  los  pacientes. 

Siendo  las  principales  complicaciones  en  la  oppracion  clasica  de  la  catarata 
debidas  unas  a  traumatismos  del  iris  y  del  vitreo  por  falta  de  tecnica  y  otras 
a  la  persistencia  dentro  del  ojo  de  la  capsula  y  restos  cristalinianos,  es  inneg- 
able  que  la  extraccion  total  simple,  por  un  procedimiento  que  no  traumatice 
ni  el  iris,  ni  el  vitreo  ni  ningun  otro  organo  intra-ocular  mas  que  la  lesion,  ni 
exija  la  practi  ca  de  presiones  sobre  el  ojo,  sera  el  mas  aproximado  a  lo  ideal. 
Con  el  Erisifaco  en  nuestra  clinica  los  accidentes  operatorios  han  quedado 
reducidos  a  una  minima  espresion  y  el  tanto  por  ciento  de  enfermos  con 
agudeza  visual  normal  ha  aumentado  considerablemente. 

No  quiero  acabar  sin  antes  invitar  a  todos  mis  companeros  a  asistir  a  mis 
sesiones  operatorias  en  Barcelona. 

Apres  avoir  remercie'  les  ophtalmologues  distingue's  qui  m'ont  permis 
d'op6rer  un  si  grand  nombre  de  malades  dans  leurs  cliniques,  et  ceux  qui  ont 
pris  part  a  cette  discussion,  je  tacherai  de  faire  remarquer  certains  points, 
les  plus  importants,  sur  mon  operation : 

1.  On  ne  doit  jamais  appeler  reparation   "aspiration  de  la  cataracte" 
toute  fois  que  la  ventouse  adhere  au  cristallin  mais  sans  rien  aspirer  de 
rinte"rieur  de  1'oeil. 

2.  La  perte  de  vitr6  n'est  pas  possible  si  on  eVite  la  moindre  pression. 


Operation  de  Barraquer  339 

Chaque  fois  qu'elle  survient  c'est  a  cause  d'un  de"faut  de  tecnique  ou  de 
preparation  du  malade. 

3.  Avec  le  vide  vibratoire  qui  casse  les  fibres  zonulaires  pre"s  du  cristallin, 
les  tractions  de  1'Erisiphaque  n'arrivent  pas  a  1'insertion  ciliaire  de  la  zonule. 

4.  Pour  ne  pas  casser  la  capsule  il  faut  re"gler  la  quantite"  de  vide  selon  les 
conditions  physiques  de  la  cataracte  a  operer. 

5.  L'Erisiphaque  est  un  instrument  de  precision  qui  doit  e"tre  soigne" 
minutieusement  et  essaye"  chaque  fois  comme  nous  fai  sons  avec  nos  couteaux 
de  Graeffe. 

6.  La  tecnique  de  Pope"ration,  telle  que  je  la  practique  n'est  pas  tres 
dificile.     L'op£rateur  qui  peut  tailler  correctement  les  lambeaux  doit  1'ap- 
prendre  facilement;  je  conside"re  plus  dificile  la  taille  du  lambeau  que  la 
manoeuvre  extraction. 

7.  J'attache  la  plus  grande  importance  a  1'^tude,  selection  et  preparation 
des  patients. 

Les  principales  complications  de  1'ope'ration  classique  reconnaissent  deux 
origines:  deTauts  de  tecnique  dans  1'acte  operatoire  et  la  persistance  dans 
1'oeil  de  re"sidus  cristallinniens  et  de  la  capsule.  Certainement  1'extraction 
totale  simple,  correctement  6x6cut4e  par  un  proce'de'  ne  traumatisant  pas 
1'iris  ni  le  vitre,  serait  le  plus  rapproch6  de.l'ideal. 

Dans  notre  clinique  nous  avons  reduit  au  minimum  les  accidents  et  releve" 
le  pourcentage  d'opere"s  avec  acuite  vasuelle  normale  depuis  que  nous  pra- 
tiquons  la  Phacoe'risis. 

J'invite  mes  confreres  americains  a  assiter  a  mes  seances  operatoires  a  Bar- 
celona. 

PROF.  EMILE  GALLEMAERTS  (closing):  L'ope"ration  de  Barraquer  per- 
mettra  de  realiser  la  maximum  de  resultata.  C'est  un  immense  progres  sur 
tout  ce  qui  a  e"te"  fait  jusqu'ici.  Pourra-t-elle  etre  execut^e  avec  toute  la 
s6curit6  qu'exige  reparation  de  la  cataracte,  1'avenir  nous  le  dira.  Nous 
pourrons  au  prochain  Congr^s  apporter  le  resultat  des  experiences  faites  dans 
nos  diff brents  pays  alors  que  nous  pourrons  discuter  cette  operation  au  point 
de  vue  pratique  aussi  bien  qu'au  point  de  vue  the"orique. 


TROUBLES  OCULAIRES  CONSECUTIFS  A 
L'OBSERVATION  DIRECTS  DE  L'ECLIPSE  SOLAIRE 

DR.  DRAGOUTINE  KOSTITCH 

Belgrade,  Jugo-Slavia 

HlSTORIQUE 

Les  effets  nocifs  des  rayons  directs  du  soleil  sur  les  yeux  sont  connus 
depuis  longtemps. 

On  savait  deja  depuis  la  plus  haute  antiquite  que  Denys,  tyran  de 
Syracuse,  les  coupables  condamnes  a  perdre  la  vue,  apres  leur  avoir 
prealablement  enleve  les  paupieres,  les  exposait  aux  rayons  directs 
du  soleil  jusqu  'au  moment  ou  leur  vision  soit  completement  abolie. 
On  sait  aussi  que  les  Carthaginois  employaient  le  meme  procede  pour 
aveugler  Attilus  Regulus. 

Plus  tard  Galien  a  observe  "des  curieux  perdre  la  vue  pour  avoir 
examine  avec  trop  d'attention  les  taches  du  soleil." 

D 'apres  Beauvais,  Galien,  Lucretius  et  Aristote  savaient  aussi  que 
les  ellipses  du  soleil  provoquent  les  troubles  de  la  vision. 

A  une  periode  plus  rapprochee  le  celebre  occuliste  du  XVIII.  siecle, 
signale  nettement  les  effets  nocifs  du  soleil.  Apres  Maitre-Jean 
(1717)  Saint- Yves  dans  son  "Nouveau  Traite  des  maladies  des 
yeux"  de  1722  dit:  "Plusieurs  personnes  ont  perdu  leur  vue  a  moitie 
pour  avoir  regarde  trop  longtemps  les  eclipses  du  soleil." 

A  la  meme  6poque  d'apres  Boyer,  le  celebre  naturaliste,  Buffon, 
apres  avoir  regarde  longtemps  le  soleil,  fut  atteint  de  mouche  volante, 
et  ce  trouble  de  la  vue  devint  insupportable  quand  ce  grand  savant 
examinait  les  objets  tres  e"  Claire's. 

Le  cas  interessant  de  Reid  dont  1'observation  a  e'te'  reproduite  par 
Mackenzie  fut  atteint  de  troubles  visuels  graves  et  permanents  en 
1761  qui  sont  survenus  a  la  suite  de  la  fixation  imprudente  du  soleil 
au  moment  du  passage  de  Venus  sur  le  disque  solaire. 

Parmi  les  Auteurs  Allemands  c'est  Plenck  en  1783  qui  cite  aussi 
quelques  cas. 

Au  XlXeme  siecle  les  observations  sont  plus  nombreuses  et  ont 
e'te  publie"es  dans  differents  ouvrages. 

Ces  accidents  sont  cites  par  Wenzel  en  1808  apres  lui  par  Demours 
en  1820  qui  a  observe  "plus  de  vingt  observations  d'amauroses  in- 

340 


Troubles  Oculaires  Consecutifs  a  V Observation  de  I'ficlipse      341 

completes  survenues  peu  apres  1'eclipse  du  soleil  du  7  octobre  1820." 
C'est  a  cet  auteur  qu'appartient  le  me*rite  d'avoir  trouve"  le  premier 
dans  ce  genre  de  malade  le  scotome  central,  car  il  cite  "mouche  fixe 
par  rapport  a  1'axe  optique."  Nous  avons  apres  les  observations 
cities  par  Larrey  "qu'il  relate  un  cas  tres  grave  chez  un  soldat,"  par 
Weller,  puis  par  Sichel  (1837)  "qui  a  donne  ses  soins  a  cinq  personnes 
qui  furent  atteintes  d'amblyopie  de  nature  torpide  chez  les  unes, 
irritatifs,  chez  les  autres  apres  avoir  trop  longtemps  fixe  le  soleil  lors 
de  Pe'clipse  qui  a  eu  lieu  en  1886,"  par  Carron  de  Villard  (1836),  par 
Rognetta,  par  Jaeger  (1851)  qui  a  trouve  les  troubles  oculaires  chez 
quatorze  personnes  a  la  suite  de  1'eclipse  solaire,  par  Van  Roosbroeck 
(1853),  par  Mackenzie  (1857)  pour  lequel  Sulzer  affirme  que  cet 
auteur  a  fait  le  premier  la  classification  de  ce  genre  de  troubles 
oculaires,  par  Desmarres  (1858). 

Plus  tard  ces  troubles  oculaires  sont  e'tudie's  dans  les  memoires 
speciaux  en  1879  et  1882  par  Dufour,  en  1882  par  Emmert,  Deutsch- 
mann,  Leber,  Haab,  Pannee  suivante  par  Reich  (un  cas),  Sulzer  (4  cas), 
Swanzy  (2  cas). 

L'e"clipse  du  soleil  du  16  au  17  mars  1887  a  donne  le  memoire  de 
Haab,  Marc  Dufour,  Sulzer,  Emmert  et  Deutschmann.  En  1890 
nous  avons  trois  cas  de  Bock  et  le  cas  de  Siegfried  de  Zurich,  en  1895 
de  Duane  et  Barret  et  en  1896  de  Collins.  A  cette  e*poque  Magavly 
le  premier  en  1887  de"crit  les  lesions  du  fond  d'oeil. 

A  la  fin  du  XIX.  siecle  nous  avons  aussi  une  eclipse  du  soleil  le  28 
mai  1900  qui  a  donne  lieu  a  de  nombreuses  publications  comme  celle 
de  Menacho  (14  cas),  Marquez  (2  cas),  Aubaret  (12),  Batten,  Sime'on 
Snelle,  Lescarret,  etc. 

Plus  tard  en  1905  on  trouve  les  observations  de  Delord  et  en  1907 
celles  de  Casali  (14  observations). 

Au  XX.  siecle  a  la  suite  de  1'eclipse  du  4  avril,  1912,  on  rencontre 
les  publications suivantes:  celles  de  Blessig(20  cas),Strahoff  (112  cas), 
Jess  (33  cas),  Katz  (6  cas),  Hirsch  (6  cas),  Lasarew  (40  cas  dont  3  avec 
retinite  perforente),  Bahtin  (1  cas),  Joffrio  (13  cas),  Viguodsky  (22 
cas),  Guermann  (4  cas),  Koubli  (8  cas),Tche'molossow;(4  cas),  Szafinski 
(11  cas),  Cords  (32  cas),  Hoppe,  Uhthoff,  Birch-Hirschfeld,  etc. 

ETIOLOGIE 

La  fixation  plus  ou  moins  prolongee  du  soleil  en  general,  comme  la 
fixation  de  T^clipse  de  cette  grande  planete  peut  provoquer  des 
troubles  oculaires. 


342  DRAGOUTINE  KOSTITCH 

Pendant  1'examen  des  taches  qui  apparaissent  a  la  surface  du  soleil 
(Galien  cite  par  Demours)  et  pendant  la  fixation  un  peu  prolongee  du 
"Passage  de  Venus  devant  le  disque  solaire"  (cas  de  Reid  cite  par 
Mackenzie,  cas  de  Swanzy  et  cas  de  Diiane)  peuvent  donner  les  acci- 
dents oculaires  ce  qui  confirme  nos  premiere  ide'es. 

Dans  les  circonstances  quand  les  rayons  solaires  entrent  en  abon- 
dance  dans  1'oeil  (comme  par  exemple  dans  le  voyage  a  travers  le 
champ  couvert  de  neige  et  le  voyage  a  travers  les  montagnes  glacees) 
peuvent  provoquer  ce  qu'on  appelle  "  Snow  Blindness  "  remarque  pour 
la  premiere  fois  deja  dans  la  plus  haute  antiquite  par  Xenophon  cite 
par  Funari.  Plus  tard  les  cas  avec  les  accidents  pareils  sont  cites  par 
Maitre-Jean  et  Saint- Yves,  Demours,  Weller,  et  Mackenzie. 

Reich  dans  son  memoire  interessant  de  1880  dans  lequel  il  decrit 
une  veritable  epidemic  de  73  ouvriers  atteints  de  "Snow  Blindness" 
a  la  suite  du  nettoyage  de  la  chaussee  transcaucasienne  couverte  de 
neige  qui  passe  a  travers  les  plus  grandes  hauteurs  du  Caucase.  Nous 
avons  encore  15  cas  semblables  a  Samara  en  Russie  et  decrits  par 
le  Dr.  Klykoff  en  1904. 

A  part  ces  troubles  oculaires  ci-dessus  decrits  on  trouve  souvent 
des  accidents  oculaires  chez  les  personnes  qui  sont  obligees  de  voyager 
a  travers  les  deserts  (Sahara),  ou  les  rayons  du  soleil  sont  en  abon- 
dance. 

Avec  le  deVeloppement  de  1'e'lectricite  nous  rencontrons  les  publica- 
tions dans  de  differents  ouvrages,  les  lesions  retiniennes  survenues  a 
la  suite  d'un  usage  du  courant  electrique. 

La  retine  peut  etre  lesee  par  les  rayons  X,  substances  radio-actives, 
acetylene,  gaz  oxyhydrique,  les  metaux  et  les  verres  en  fusion,  etc. 

Malgre  qu'on  trouve  les  accident  oculaires  pendant  la  fixation  a 
1'oeil  nu  de  1'eclipse  solaire,  on  rencontre  aussi  ces  troubles  oculaires 
chez  les  personnes  qui  "  Ensuivant  les  diverges  phases  de  1'eclipse  dans 
un  baquet  plein  d'eau  qui  reflechissait  1'image  du  soleil"  (Demours), 
fixation  de  1'image  du  soleil  dans  un  miroir  ou  dans  1'eau  (Casali), 
quand  on  regarde  1'eclipse  a  travers  les  doigts  (Betten) ;  La  fixation  de 
1'eclipse  avec  les  mains  en  cornet,  ou  a  travers  le  verre  non  suffisam- 
ment  noirci  (Villard  et  Kostitch),  a  travers  le  verre  irregulierement 
noirci  (Demours  et  Larrey)  en  fixant  a  travers  le  verre  colore"  par  une 
couleur  mal  choisie  (Berret,  James  et  Snell)  a  travers  une  carte  a 
jouer  trouee  au  milieu  {Strakhoff),  fixation  par  un  telescope  imprudem- 
ment  manie  (Lawrance,  Regretta,  Snell)  et  enfin  a  travers  un  trou 
pratique  dans  un  verre  fume  (Strakhoff). 


Troubles  Oculaires  Consecutifs  a  VObservation  de  V Eclipse      343 

La  duree  de  1'observation  de  1'eclipse  solaire  est  differente  dans 
differents  cas.  Dans  le  cas  de  Barret  la  duree  de  fixation  etait  de  15 
minutes,  dans  celui  de  Colins  de  5  a  10  minutes,  dans  le  cas  personnel 
de  3  a  30  minutes  et  dans  un  cas  d'un  auteur  Russe  la  dur6e  a  &£  de 
40  minutes.. 

Lazareff  croit  comme  la  loupe  ramasse  les  rayons  du  soleil  quand  on 
veut  a  1'aide  de  celle-ci  allumer  la  cigarette  ou  un  morceau  de  papier, 
le  cristallin  a  le  meme  role  dans  le  cas  de  lesion  retinienne  survenue 
pendant  1'observation  a  1'oeil  nu  de  1'eclipse  solaire  par  rapport  a  la 
macula  laquelle  doit  etre  brulee  sous  1' influence  des  rayons  directs  du 
soleil  ramasses  par  le  cristallin  et  concentres  sur  la  retine. 

SYMPTOMATOLOGIE 

Ordinairement  ces  "accidents  oculaires"  qui  arrivent  comme  con- 
sequence de  1'examen  direct  de  1'eclipse  apparaissent  immediate- 
ment  apres  la  fixation  de  ce  corps  celeste.  Mais  les  victimes  de  ce 
phenomene,  ordinairement  au  commencement  ne  font  pas  attention  a 
ces  "accidents  oculaires,"  en  croyant  que  c'est  "la  simple  prolonga- 
tion de  1'eblouissement  habituellement  observe  quand  on  regarde 
trop  longtemps  ou  de  trop  pres  un  corps  incandescent  et  tres  lumi- 
neux." 

Beaucoup  de  ces  malades  immediatement  apres  la  fixation  de 
1'eclipse  solaire  a  1'oeil  nu  se  plaignent  de  voir  se  promener  devant 
les  yeux  une  tache  verte  (obs.  No.  7)  tache  sombre  comme  la  poussiere 
(Obs.  No.  11)  tache  jaune  (Obs.  No.  12)  tache  jaune  verdatre  (Obs. 
No.  13),  une  tache  qui  au  debut  etait  rouge  claire  puis  violace"e  et 
enfin  est  devenue  jaunatre  (Obs.  No.  14)  et  enfin  une  tache  noire  (Obs. 
No.  16).  Un  malade  de  Lazareff  se  plaignait  de  voir  un  "cheval 
vert." 

II  y  a  certains  malades  qui  ne  voyaient  pas  les  mots  entiers  pendant 
la  lecture,  d'autres  perdaient  certaines  lettres  et  en  cherchant  a  les 
voir  pendant  la  lecture  ils,  arrivaient  finalement  mais  perdaient  les 
lettres  voisines. 

D'autres  malades  se  plaignaient  que  certaines  lettres  leur  parais- 
saient  etre  couvertes  par  une  espece  de  tache  d'encre. 

Une  de  nos  malades  se  plaignait  qu'elle  voyait  son  mari  mais 
n'apercevait  pas  "  le  milieu  de  la  tete." 

Un  autre  de  nos  malades  (Obs.  No.  4  or  13)  qui  depuis  1'eclipse 
d'avril  de  cette  annee  se  plaint  que  la  vision  de  son  oeil  gauche  est 
troublee,  mais  il  accuse  d'avoir  pendant  la  lecture  un  point  noir,  qui 


344  DRAGOUTINE  KOSTITCH 

1'empechait  de  voir  deux  ou  trois  lettres  de  chaque  mot  qu'il  lisait  et 
au  lieu  de  ces  lettres  il  voyait  une  tache  bleu  verdatre  dont  le  vert 
e*tait  tres  fence*  qui  ressemblait  a  une  tache  d'encre. 

L'Etat  du  Fond  D'Oeil. — A  1'ophtalmoscope  on  de*cele  des  lesions 
du  fond  d'oeil  provoque*es  par  la  fixation  a  1'oeil  nu  plus  ou  moins  long- 
temps  de  l'e*clipse  solaire.  Ces  lesions  pourtant,  surtout  immediate- 
ment  apres  la  fixation  sont  souvent  malgre  les  troubles  de  la  vision 
introuvables  par  1'ophtalmoscope  et  le  fond  d'oeil  parait  tout-a-fait 
normal  comme  dans  les  cas  de  Emmert,  Swanzy,  Bocca,  Duane, 
Snell,  Lawward,  Aubaret,  Menacho  et  observations  personnelles. 

Comme  nous  venons  de  le  dire  plus  haut  quand  la  lesion  du  fond 
de  1'oeil  existe,  on  voit  a  1'ophtalmoscope  quelque  fois  la  coloration  plus 
intense  de  la  tache  jaune  (Reich,  Schirmer)  d'autres  fois  on  remarque 
une  pigmentation  plus  intense  de  cette  region  (Sulzer  et  Dufour)  ou 
1'oedeme  de  macula.  Mais  de  tous  ces  changements  du  fond  d'oeil 
on  voit  le  plus  souvent  au  niveau  de  la  macula  des  taches  rouges  noires 
ou  de  la  couleur  des  framboises,  ce  qui  prouve  qu'il  y  a  une  congestion 
plus  ou  moins  intense  dans  cette  region  (Swanzy,  Bocca,  Aubaret, 
Menacho.  Delord,  Vigodsky,  Joffrio,  Bourzeff). 

Les  lesions  vues  a  1'ophtalmoscope  peuvent  etre  quelquefois  plus 
intenses  que  celles  que  nous  venons  de  citer  plus  haut.  Lazareff  a 
trouve  chez  trois  malades  apres  une  fixation  longue  a  1  (oeil  nu  de 
l'e*clipse  solaire,  la  perforation  de  la  retine  au  niveau  de  la  macula. 

PATHOGENIE 

Nombreux  sont  les  auteurs  qui  ont  fait  differentes  experiences 
par  les  rayons  solaires  sur  les  yeux  de  differents  animaux  pour  ex- 
pliquer  les  lesions  de  1'oeil,  que  1'on  trouve  chez  1'homme  que  dans  les 
troubles  provoque's  par  1'eclipse  solaire. 

Parmi  ces  auteurs  c'est  Czerny  (1867)  a  le  premier  commence  par 
les  experiences  pareilles  sur  les  animaux,  apres  lui  c'est  Deutschmann 
(1882),  Widmark  (1890),  Aubaret  et  Lescaret  (1907)  et  Birch  Hirsch- 
feldt  (1912). 

Czerny  et  Deutschmann  apres  avoir  prealablement  dilate*  la  pupille 
d'une  grenouille  et  d'un  lapin  concentraient  a  1'aide  d'un  miroir  con- 
cave ou  d'une  lentille  convexe  des  rayons  du  soleil  sur  la  re*tine  des 
animaux  en  experience. 

Apres  1'effet  de  dix  a  quinze  minutes  de  ces  rayons  ils  observaient  sur 
la  retine  a  1'aide  de  1'ophtalmoscope  une  tache  claire  entouree  par  une 


Troubles  Oculaires  Consecutifs  d  I1  Observation  de  I'ficlipse      345 

aureole  jaunatre  ou  grisatre  et  un  peii  plus  tard  la  couleur  d'aure'ole 
devenait  d'abord  rougeatre  puis  brune  et  enfin  presque  noire. 

Pendant  trois  semaines  le  processus  de  cette  lesion  evoluait,  les 
couleurs  changeaient  et  finalement.il  se  formait  au  centre  du  foyer 
retinien  une  tache  durable. 

Au  bout  d'un  certain  temps  on  enucie"ait  les  yeux  en  experience  et 
apres  un  examen  histologique  on  constatait  que  ce  sont  les  couche  des 
fibres  nerveuses,  des  cones  et  batonnets,  et  la  couche  des  granula- 
tions internes  qui  subissent  le  plus  de  degats. 

Dans  ces  couches  ci-dessus  citee"s,  il  se  forme  une  degenerescense 
granulaire  avec  un  developpement  hypertropique  des  cellules 
fibrineuses. 

II  est  difficile  d'adapter  Foeil  experimente  pour  que  les  rayons 
solaires  tombent  juste  sur  les  fovea,  sur  la  macula.  Puisque  la 
macula  est  composee  surtout  de  cones  et  batonnets  et  couches  granu- 
leuses  externes,  il  est  comprehensible  que  les  lesions  sur  ce  lieu  soient 
d'un  caractere  severe  (Lazareff). 

Strahoff,  croit  que  les  cones  et  batonnets  paraissent  etre  plus 
leses  a  cause  d'une  couche  pigmentaire  qui  se  trouve  derriere  et  qui 
attire  beaucoup  les  rayons  lumineux. 

Birch-Hirschfeld  a  expose  les  yeux  de  lapins  aux  rayons  solaires 
dans  les  conditions  qui  se  r'approchent  le  plus  aux  conditions  de 
1'eclipse  solaire. 

Par  les  recherches  microscopiques  deja  experimentees  il  a  trouv6 
une  hyperemie  choroidale,  1'oedeme  de  la  couche  pigmentaire  et  la 
degenerescence  de  la  partie  externe  de  'la  retine. 

Dans  ces  experiences  de  1'exposition  des  yeux  de  lapins  aux  rayons 
ultra-violets  Birch-Hirschfeld  est  arrive  aux  resultats  contraires  de 
ses  premieres  experiences,  il  a  trouve  que  la  partie  externe  de  la  retine 
etait  intacte  mais  la  couche  des  cellules  ganglionaires  et  la  couche  granu- 
leuse  interne  etaient  lesees.  Les  rayons  ultra-violets  sont  absorbes 
par  la  couche  interne  de  la  retine,  mais  les  rayons  lumineux  traversent 
cette  couche  et  ne  sont  absorbes  que  par  la  couche  pigmentaire,  par 
consequent  les  degats  de  la  retine  qui  dependent  de  1'influence  des 
rayons  solaires  pendant  1'eclipse  se  resument  par  une  necrose  coagul- 
lente  provenant  le  1'epithelium  de  la  vision  et  par  exudation  de  la 
choroide. 

De  ces  experiences  on  voit  que  les  rayons  calorifiques  ne  sont  pas 
nuisibles  comme  les  rayons  lumineux. 

Aubaret  et  Lescaret  ont  fait  quatre  experiences  sur  des  lapins,  en 


346  DRAGOUTINE  KOSTITCH 

exposant  durant  20  a  40  minutes  les  yeux  de  ces  animaux  aux  rayons 
calorifiques,  1'autre  aux  rayons  chimiques  et  les  yeux  des  deux  derniers 
aux  rayons  solaires. 

Ces  auteurs  sont  loin  des  re"sultats  de  leurs  devanciers.  Apres 
1'examen  ophtalmoscopique  immediat  et  les  jours  suivants  ils  n'arri- 
vent  pas  a  deceler  les  lesions  apparentes.  A  1'examen  microscopique 
apres  e"nucleation  de  1'oeil  experimente  ils  n'ont  pas  pu  trouver  la  partie 
e"blouie  de  la  retine.  Aubaret  dans  son  travail  public  dans  les  archives 
d'ophtalmologie  du  fevrier  1907  se  borne  a  critiquer  le  precede  de 
1'experimentation  de  ses  devanciers  en  abolissant  leurs  theories  que 
la  radiation  calorifique  et  chimique  peuvent  produire  photo-trauma. 
Pour  lui  la  radiation  lumineuse  seule  produit  le  photo-trauma. 

SCOTOME  CENTRAL 

C'est  Emmert  qui  a  donne  le  nom  de  scotome  helie'clipticum  et  le 
nom  de  scotome  helioplegicum  est  donn6  par  Szafinsky. 

Dans  les  incidents  oculaires  provoques  par  Peclipse  on  trouve  pres- 
que  toujours  un  scotome  qu'on  nomme  ordinairement  scotome 
he'lieclipticum  ou  scotome  helioplegicum.  Quelquefois  on  ne  trouve 
pas  de  scotome  ou  meme  s'ils  existent  ils  sont  si  petits  qu'on  ne  peut 
pas  les  definire  par  le  perimetre  ordinaire  et  ces  scotomes  peuvent  etre 
psychiquement  annules  par  les  malades. 

Le  scotome  est  le  plus  souvent  central  et  les  cas  de  scotome  para 
central  sont  plus  rares. 

Dans  certaines  observations  publiees  on  trouve  les  scotomes  "posi- 
tifs"  comme  une  tache  eblouissante  et  dans  1'autre  le  scotome  "nega- 
tif  "  c'est  a  dire  le  scotome  qui  se  manifeste  par  un  petit  deficit  dans  le 
champ  visuel.  Quand  a  la  forme  de  ce  scotome  c'est  la  forme  circu- 
laire  "Ring  scotome"  qui  est  la  plus  habituelle.  Par  les  examens 
scotometriques  (Jess)  on  est  arrive  a  conclure  que  la  forme  du  scotome 
correspond  au  optograme  du  soleil  est  rare  (Birch-Hirschfeld). 

La  forme  de  ce  scotome  central  est  quelquefois  ovale. 

Dans  un  cas  curieux  de  Duane  relatif  a  1'observation  du  passage  de 
Venus  devant  le  soleil,  ce  scotome  avait  une  forme  circulaire  avec 
un  e"chancrure  a  la  partie  supe"rieure  et  reproduisait  exactement  la 
forme  du  disque  solaire  au  moment  de  1'observation. 

Le  scotome  d'apres  Aubaret  consiste  dans  un  edeme  locale  de  la 
ratine  et  d'apres  Villard  correspond  a  une  he"morragie  locale  de  la 
re"  tine. 

L'influence  de  V eclipse  solaire  sur  I'acuite  visuelle. — L'acuite*  visuelle 


Troubles  Oculaires  Consecutifs  a  ^Observation  de  I'fidipse      347 

chez  les  malades  qui  ont  des  accidents  oculaires  survenue  a  la  suite 
de  fixation  a  1'oeil  nu  de  1'eclipse  solaire,  peut  etre  de  0.8-0.9,  ou  Pacuite" 
peut  etre  normale.  Mais  il  y  a  des  cas  dans  lesquels  1'acuite"  visuelle 
est  de  0;  la  0.2. 

Les  cas  ou  la  vision  est  presque  normale  s'expliquent  par  le  fait  que 
la  lesion  de  la  retine  n'occupe  pas  toute  la  fovea  centrale  de  la  macula. 

Dans  certains  cas  le  malade  peut  ameliorer  sa  vision  par  une  fixa- 
tion excentrique  c'est  a  dire  par  une  deviation  de  1'oeil  pendant  le 
regard,  et  par  ce  fait  1'objet  n'est  pas  fixe  par  le  centre  de  macula,  mais 
il  est  fixe  par  les  autres  parties  de  macula  qui  ne  sont  pas  si  lesees  que 
la  fovea  centrale.  Par  cela  on  peut  conclure  en  dehors  de  centre  de  la 
macula  que  les  autres  parties  de  celle-ci  restent  intactes  (Strahoff). 

LE  RAPPORT  ENTRE  LES  TROUBLES  ET  LA  REFRACTION 

Theoriquement  les  yeux  des  emmetropes  sont  plus  exposes  aux 
lesions  pendant  la  fixation  que  ceux  des  hypermetropes  et  myopes. 

Dr.  Tchemolossoff  de  Petrograd  a  public  un  cas  qui  correspond  a 
1'hypothese  ci-dessus. 

Une  jeune  femme  bien  portante  a  fixe  avec  les  deux  yeux  nus 
1'eclipse  solaire;  elles  n'a  eu  les  troubles  oculaires  qu'a  un  seul  oeil 
qui  etait  emmetrope.  L'autre  oeil  dont  la  refraction  etait  myopique 
est  reste  sans  aucun  accident. 

Nous  avons  aussi  comme  chez  notre  malade  obs.  No.  18  1'oeil 
Emmetrope  etait  lese  et  1'autre  oeil  hypermetrope  resta  intact. 

COMPLICATION 

Marquez  a  public  un  cas  dans  lequel  aussitot  apres  la  fixation  a 
1'oeil  nu  de  1'eclipse  solaire,  il  a  trouve  ophtalmoscopiquement  une 
grande  congestion  des  papilles  et  neuroretinite  dans  les  deux  yeux.  Les 
atrophies  des  nerfs  optiques  arrivent  ordinairement  comme  complica- 
tion tar  dive. 

Comme  nous  1'avons  deja  remarque  Lazareff  a  trouve  trois  cas  dans 
lesquels  il  a  constate,  bientot  apres  la  fixation,  la  perforation  de  la 
retine  au  niveau  de  la  region  maculaire. 

Batten  a  trouve  un  cas  de  trombose  d'une  artere  re"tinienne  et  un 
autre  cas  d'hemorragie  de  la  retine. 

Menacho  a  eu  1'occasion  de  voir  14  malades  qui  ont  pre'sente'  dif- 
fe*rentes  complications  de  1'oeil  survenues  a  la  suite  de  l'e"clipse  solaire. 

De  ces  14  observations  un  malade  presentait  une  papillite  centrale,  2 
malades  presentaient  de  1'  hyalite,  1  cas  d'apoplexie  maculaire,  un  autre 


348  DRAGOUTINE  KOSTITCH 

une  nevrite  re"tro-bulbaire ;  une  f ois  il  a  trouve"  chez  un  malade  de  la  lym- 
phangite  anterieure  avec  glaucome  et  enfin  deux  fois  des  nevrites 
optiques. 

Sulzer  a  trouve"  aussi  un  cas  de  neuro-re'tinite. 

Ste"phenson  a  constate"  un  cas  de  nevrite  legere. 

Katz  de  ces  6  observations  a  trouve*  un  cas  de  conjonctivite  avec 
ke"ratite  du  limbe.  (2e)  cataracte  polaire  poste"rieure;  (3e)  paralysie 
du  sphincter  pupillaire. 

Marenholtz  a  trouve  un  cas  de  nevrite  optique. 

Hirsch  de  6  cas  il  a  remarque  chez  trois  malades  de  conjonctivite. 

Jssakowitz  a  observe  un  cas  de  l'e"blouissement  du  cristallin.  Nous 
avons  trouve"  aussi  un  cas  de  conjonctivite  (obs.  No.  19). 

Aubaret  et  Villard  pensent  que  les  complications  graves  survenues 
a  la  suite  le  la  fixation  de  l'e"clipse  sont  rares  et  arrivent  &  1'hypothese, 
a  part  des  rayons  solaires  qu'il  y  a  d'autres  causes  qui  provoquent  ces 
troubles  oculaires. 

Ainsi  Aubaret  pense  que  la  complication  d'hyalite  chez  des  malades 
cite"e  par  Menacho  n'est  pas  survenue  a  la  suite  de  fixation  de  1'eclipse, 
mais  qu'elle  est  survenue  a  cause  de  la  myopie  forte,  qui  existait  chez 
ces  malades  deja  avant  1'eclipse. 

Villard  a  public  une  observation  d'un  malade  fortement  myope 
chez  lequel  il  a  trouve  un  de'collement  de  la  retine  a  la  suite  de  fixation 
de  l'e"clipse.  Get  auteur  croit  que  cette  complication  n'est  pas  arrivee 
comme  consequence  de  Faction  des  rayons  directs  du  soleil. 

Fromaget  a  constate"  chez  un  malade  a  la  suite  de  1'eclipse  une 
choroidite  se"reuse,  mais  ce  malade  souffrait  pendant  6  ans  avant 
l'e"clipse  de  sinusite  maxillaire  du  meme  cote. 

PRONOSTIC 

Dans  cette  maladie  le  pronostic  doit  etre  toujours  reserve*.  II  y 
a  des  cas  qui  guerissent  assez  rapidement,  dans  lesquels  1'acuite 
visuelle  devient  presque  normale  ou  tout  a  fait  normale.  Le  petit 
scotome  qu'on  rencontre  chez  ces  malades  disparait  aussi  assez  rapide- 
ment. Dans  d'autres  cas  1'acuite"  visuelle  s'ame'liore  seulement  au 
bout  de  4  a  6  mois  et  elle  n'aboutit  que  jusqu'a  0.5  a  0.6.  Le  scotome 
ne  disparait  pas  chez  ces  malades,  a  cause  de  la  disparition  des  cones  et 
des  batonnets  au  ni  veau  du  centre  de  la  macula  qui  sont ' '  brules  "par  les 
rayons  directs  du  soleil.  Malheureusement  comme  ces  elements  ne  se 
re"generent  pas,  ces  malades  sont  condamne's  a  supporter  ce  scotome 
eternellement. 


Troubles  Oculaires  Consecutifs  d  I 'Observation  de  1'eclipse     349 

Dans  certains  cas  le  pronostic  est  encore  plus  grave.  "Maitre 
Jean  fait  allusion:  toutes  ces  choses  disparaissent  quand  les  fibres  de 
la  retine  se  remettent  dans  leur  etat  normal;  mais  quand  le  vice  que 
ces  fibres  ont  contractee  est  considerable  il  continue  quelquefois  a 
paraitre  tout  le  reste  de  la  vie." 

Saint- Yves  signaler  "Des  personnes  qui  ont  perdu  la  vue  a  moitie 
pour  avoir  regarde  trop  longtemps  des  eclipses  du  soleil." 

Rognetta  cite  un  cas  qui  resta  completement  aveugle. 

De  Wecker  croit  que  I'abaissement  de  1'acuite  visuelle  et  le  scotome 
peuvent  rester  e'ternellement. 

Reich  a  constate"  un  cas  ou  1'acuite"  visuelle  est  reste  a  0.3  pour  tou- 
jours  avec  scotome  central  persistant  pour  les  couleurs. 

Dans  le  cas  de  Winsellmann  1'acuite  visuelle  a  ete  presque  nulle 
pendant  3  ans  a  partir  du  commencement  des  accidents  oculaires. 

Dans  1'observation  de  Collins:  "Les  troubles  de  1'oeil  le  plus  atteint 
n'avaient  pas  sensiblement  diminues  9  ans  plus  tard." 

Duane  cite  un  cas  dans  lequel  le  scotome  existait  pendant  12  ans 
apres  le  debut  des  accidents,  avec  la  complication  d'attaque  d'hemi- 
anopsie. 

Aubaret  a  constate*  chez  un  malade  apres  45  ans  de  1'eclipse  solaire 
un  scotome  helieclipticum,  avec  une  diminution  de  1'acuite  visuelle 
de  2/3  et  dans  un  autre  cas  il  trouva  un  scotome  apres  28  ans  de 
1'eclipse  solaire. 

TRAITEMENT 

La  plupart  des  auteurs  conseillent  au  point  de  vue  prophylactique 
de  ne  regarder  le  soleil  qu'a  travers  des  verres  fortement  teintes,  qui 
atte"nuent  beaucoup  1'intensite  des  rayons  qu-il  emet.  Les  verres 
employes  doivent  etre  suffisamment  teinte's  en  noir.  Autrement, 
comme  on  1'a  deja  constate,  si  Ton  fixe  1'eclipse  solaire  a  travers  le 
verre  insuffisamment  teinte;  dans  ce  cas  les  troubles  oculaires  peuvent 
se  produire,  aussi  bien  dans  le  cas  de  fixation  a  1'oeil  nu. 

Certains  auteurs  comme  Holden  ont  conseille  de  superposer  trois 
verres,  un  rouge,  un  vert  et  un  bleu.  II  parait  que  ces  verres  colores 
bien  choisis  "ne  changeraient  en  rien  la  couleur  du  soleil,  tout  en 
affaiblissant  suffisamment  son  intensite  lumineuse  pour  en  rendre 
1'observation  directe  inoffensive  pour  1'oeil." 

Quand  le  malade  s'adresse  au  me"decin  imme'diatement  apres  les 
accidents,  il  faut  mettre  les  yeux  du  malade  au  repos  complet.  Le 
malade  ne  doit  pas  quitter  la  chambre;  laquelle  doit  etre  peu  eclaire"; 
on  ordonnera  un  purgatif  que  Ton  renouvellera  plusieurs  fois;  on 


350  DRAGOUTINE  KOSTITCH 

prescrira  des  saign6es  locales  (vantouses  scarifiers  de  Heurteloup), 
on  peut  conseiller  aussi  1'injection  de  strychnine;  enfin  plus  tard  on 
donnera  de  1'iodure  de  potassium. 

A  part  ce  traitement  nous  avons  conseille1  a  nos  malades  qui  etaient 
presque  tous  des  Sieves  du  Lycee,  de  quitter  l'6cole  provisoirement  et 
de  passer  leurs  vacances  a  la  campagne  dans  la  verdure. 

Le  plus  part  de  nos  malades  ont  acceptes  notre  conseil,  d'autant 
plus  que  1'eclipse  solaire  du  9  avril  est  tomb6  juste  avant  la  fin  de 
1'annee  scolaire. 

LES  OBSERVATIONS 

06s.  No.  1. — Zagarka  Popovitch,  age*  de  23  ans.  Bonne. 

Le  9  avril  elle  a  fixe*  avec  les  deux  yeux  Peclipse  solaire  a  10  heures  du 
matin.  Apres  une  courte  fixation  des  deux  yeux  elle  a  continue"  a  fixer  pen- 
dant une  demi-heure  avec  1'oeil  droit  seulement.  Tout  de  suite  apres  la 
fixation  elle  a  perdu  la  vision  momentanement,  mais  aussitot  la  vision  est 
revenue  surtout  a  1'peil  gauche,  et  la  vision  s'est  amelire  difficilement,  mais 
comme  nous  verrons  plus  tard  Pacuite*  visuelle  surtout  de  Poeil  droit  est 
reste"  en  defaut. 

13  avril  10  D.  Devant  cet  oeil  elle  a  une  tache  qui  lui  a  trouble  cet  oeil. 
La  couleur  de  cette  tache  au  debut  etait  jaune  puis  verte  et  enfin  est  devenue 
rouge.  La  malade  a  declare*  qu'avec  1'oeil  droit  elle  voyait  son  mari  mais 
elle  ne  lui  voyait  pas  le  milieu  de  la  figure.  Son  acuite  visuelle  a  etc*  le  13 
avril  de  0.7.  Done  chez  cet  oeil  existe  le  scotome  central. 

A  Pexamen  ophtalmoscopique  on  voyait  que  P aureole  de  la  macula  etait 
e*bloui,  et  dans  le  centre  de  la  macula  on  voyait  un  petit  cercle  de  couleur 
foncee  et  vers  la  peripheiie  de  ce  centre  il  existait  une  petite  tache  jaune. 

0.  G.    Pas  de  scotome.    F.  0.  normale  V.  =  0.9. 

A  la  sciascopie  les  deux  yeux  Etaient  emmetropes. 

19  avril  O.  D.    Sans  changement.     0.  G.  V.  =  1. 

06s.  No.  2. — A.  D.  eleve  du  Lycee.  II  a  fixe"  Peclipse  du  9  avril  2  fois  avec 
1'oeil  droit  nu  en  fermant  1'oeil  gauche.  Le  lendemain  il  a  remarque  que  sa 
vision  n'etait  pas  si  bonne  qu'avant,  et  surtout  une  tache  grisatre  persistante 
devant  cet  oeil  le  genait. 

Le  12  avril.  0.  D.  V.:  0.5.  En  lisant  il  ne  voit  que  chaque  troisieme 
lettre  du  mot  F.  0.  macula  avec  un  aureole  clair,  dans  le  centre  de  la  macula 
une  petite  tache  rouge  fonce*e.  Petit  scotome  central.  O.  G.  normal.  A  la 
Sciascopie  les  deux  yeux  sont  &nm6tropes. 

4  octobre,  meme  annee.  O.  D.  V.:  1.  Disparition  de  la  tache.  F.  0. 
La  petite  tache  de  la  macula  est  diminuee.  Pas  de  scotome. 

06s.  No.  3. — F.  F.  Age*  de  14  ans,  eleve  du  Lycee  a  fixe"  le  9  avril,  1921,  avec 
1'oeil  gauche  nu  Peclipse  solaire  pendant  4  a  5  minutes.  Aussitot  il  a  remar- 


Troubles  Oculaires  Consecutifs  a  V Observation  de  I'ficlipse      351 

quo*  que  la  vision.de  cet  oeil  e"tait  trouble  et  en  meme  temps  une  petite  tache 
persistante  se  promenait  devant  cet  oeil ,  pendant  la  lecture  il  ne  voyait  pas 
certaines  lettres  du  meme  mot. 

14  avril.  0.  D.  normal.  0,  G.  F.  0.  Toute  la  region  de  la  macula  e"tait 
couverte  on  dirait  par  une  se"rosite"  qui  empechait  de  voir  les  de" tails  de  cette 
region.  Scotome  central  tres  grand.  V. :  0.3. 

20  septembre.  0.  G.  F.  0.  Au  niveau  du  centre  de  la  macula  une  tache 
gris  fonce".  Scotome  existe  encore.  V.:  0.6.  0.  D.  normal. 

06s.  No.  4- — M.  V.  e"leve  du  Lycee,  age  de  17  ans,  a  fixe"  le  9  avril  au  de"but 
avec  les  deux  yeux  a  travers  le  verre  fume"  l'e"clipse  solaire.  Au  bout  d'un 
certain  temps  il  a  continue"  a,  fixer  avec  1'oeil  gauche  nu  a  peu  pres  pendant  20 
minutes.  Son  oeil  droit  pendant  la  fixation  e"tait  ferine".  Aussitot  il  a  re- 
marque"  un  e"blouissement  et  la  fatigue  des  deux  yeux.  Cet  e"blouissement 
n'est  pas  e"te"  de  longue  dure"e,  mais  devant  son  oeil  gauche,  persistait  une 
tache  1'empechant  de  voir  deux  ou  trois  lettre  de  chaque  mots.  A  la  place  de 
ces  lettres  il  voyait  une  tache  de  la  couleur  bleu  verdatre-fonce*. 

11  avril.  O.  D.  normal.  O.  G,  V.:  0.4.  F.  0.  Dans  le  centre  de  ma- 
cula on  trouve  une  tache  en  forme  de  demi  cercle  de  couleur  rouge  fonc6. 
Scotome  central  positif. 

20  avril.     0.  D.  normal.     0.  G.    V.:  0.7.    Le  reste  sans  changement. 

1  octobre.    O.  D.  normal.     0.  G.    Scotome  central  positif  V.:  0.7.    F.  0. 
Petite  tache  blanche  dans  la  region  maculaire. 

06s.  No.  5. — Le  nomine"  M.  V.  416 ve  du  Lycee  age*  de  16  ans  a  fixe"  avec 
1'oeil  gauche  nu  Eclipse  solaire  du  9  avril  1921.  Aussitot  il  a  remarque"  une 
tache  devant  cet  oeil  qui  lui  cachait  une  partie  de  petits  objets.  Cette  tache 
a  duree  pendant  2  jours.  Nous  ne  1'avons  vu  que  7  jours  apres  1'accident. 
II  n'avait  pas  de  scotome.  0.  D.  normal.  O.  G.  le  contour  du  macula 
n'etait  pas  tres  net.  L'acuite"  e"tait  normale  aux  deux  yeux. 

2  septembre.     Les  deux  yeux  e"taient  normaux. 

06s.  No.  6. — Le  nomine"  M.  Man,  age"  de  11  ans  e"leve  du  Re*al  gymnase. 
Ce  malade  a  fixe"  Pe"clipse  solaire  du  9  avril  deux  fois  avec  les  deux  yeux  nus. 
Chaque  fois  la  dure"e  de  fixation  e"tait  de  10  a  15  minutes.  Apres  la  fixation  il 
est  rentre"  en  classe  pour  travailler,  mais  quand  il  a  commence"  a  lire  toutes  les 
lettres  lui  semblait  etre  couvertes  par  des  points  noirs  ou  plutot  comme  il 
disait  couvertes  de  "taches  d'encre."  En  meme  temps  les  lignes  imprime*es 
lui  semblaient  etre  interrompues  par  places.  Nous  1'avons  vu  le  lendemain 
de  la  fixation  c'est-a  dire  le  10  avril,  1921. 

0.  G.  F.  0.  Tout  le  centre  de  macula  e"tait  couvert  par  une  tache  rouge 
fortement  fonce"e.  A  la  partie  infe"rieure  de  cette  tache  on  voyait  un  petit 
point  jaune  comme  une  tete  d'epingle.  L'aure"ole  de  la  macula  e"tait  forte- 
ment hyp6re"mie"e.  V. :  0.2. 

0.  D.    F.  0.    Tout  Paure"ole  de  la  macula  e*tait  oedemacie"e  et  la  partie  in- 


352  DRAGOUTINE  KOSTITCH 

fe>ieure  e"tait  presque  bleu&tre.  Au  centre  de  macula  existait  une  tache 
fortement  rouge.  V.:  0.3.  Le  soleil  le  gene  beaucoup.  Le  scotome  central 
des  deux  yeux  e"tait  positif. 

10  octobre,  meme  anne"e.  Le  scotome  positif  des  deux  yeux  0.  G.  V.:  0.2. 
F.  O.  aureole  maculaire  pas  nette.  Au  centre  de  la  macula  on  voit  un  petit 
cercle  rouge  avec  un  point  blanc  au  centre.  0.  D.  V.:  0.3.  F.  0.  aureole 
maculaire  pas  nette. 

Le  malade  lit  un  peu  plus  facilement  mais  encore  assez  difficilement  de 
telle  sorte  qu'il  e"tait  oblige"  de  repasser  ses  examens  a  la  session  de  novembre. 

06s.  No.  7.— R.  B.  e"leve  du  Lyc6e  age"  de  10  ans.  II  a  fixe"  pendant  2-3 
minutes  avec  les  deux  yeux  1'e'clipse  solaire.  Le  meme  jour  il  avait  devant 
les  deux  yeux  une  tache  verdatre.  Au  bout  de  quelques  jours  cette  tache 
avait  disparue.  Nous  1'avons  vu  le  12  avril.  Pas  de  scotome.  Les  taches 
persistent.  F.  0.  Aux  deux  yeux  normaux  ainsi  que  1'acuite1  visuelle. 

06s.  No.  8. — M.  S.  eleve  du  Lyce"e,  age"  de  13  ans.  Le  malade  a  fixe"  avec 
1'oeil  droit  pendant  3-4  minutes,  1'e'clipse  solaire  du  9  avril,  1921.  II  y  a  eu 
une  tache  devant  cet  oeil  aussitdt  mais  elle  a  disparue  le  lendemain.  Les 
lignes  et  les  lettres  lui  semblaient  etre  courbe's.  Nous  1'avons  vu  le  11  avril, 
1921.  O.  D.  V.:  1  F.  O.  normal. 

06s.  No.  9. — B.  M.  eleve  du  Lyce"e,  age"  de  12  ans.  A  fixe"  plusieurs  fois  dans 
la  matinee  du  9  avril  1'e'clipse  solaire  avec  1'oeil  droit  tantot  nu,  tantot  & 
travers  le  verre  fume".  Le  meme  jour  il  avait  une  tache  bleu-verdatre  de- 
vant cet  oeil.  En  lisant  il  ne  voyait  pas  certaines  lettres  de  chaque  mot. 
Nous  1'avons  vu  le  12  avril.  Ce  malade  pre"sentait  &  1'oeil  gauche  un  petit 
scotome.  V. :  0.9.  F.  0.  hype're'mie  le"gere  de  la  macula. 

10  aout.    0.  D.    V.:  1.    Pas  de  scotome.    F.  0.  normal. 

06s.  No.  10. — J.  C.  Eleve  du  Lyce"e,  age"  de  13  ans,  a  fixe"  avec  les  deux 
yeux  1'e'clipse  solaire  du  9  avril,  plusieurs  fois  pendant  2-3  minutes.  Dans 
la  meme  journe"e  il  a  remarque"  devant  son  oeil  guache  une  tache;  pourtant 
devant  1'oeil  droit  qui  est  strabique  n'a  rien  remarque".  II  est  venu  chez  nous 
le  10  avril  1921. 

0.  D.  V.:  0.1  Pas  de  scotome.  Strabisme  convergent.  F.  0.  normal. 
Pas  de  tache  subjective.  0.  G.  V.:  entre  0.9  et  1.  Pendant  la  lecture  les 
lignes  sont  troubles.  La  tache  persiste.  Petit  scotome  central. 

06s.  No.  11. — A.  A.  age"  de  14  ans,  a  fixe"  le  9  avril  avec  1'oeil  droit  3  fois 
1'e'clipse  solaire.  Le  meme  jour  il  a  remarqu^  une  tache  devant  cet  oeil  qui 
1'empeche  de  lire.  Cette  tache  lui  semble  comme  une  petite  poussiere.  Le 
1 1  avril  il  est  venu  chez  nous.  O.  D.  V.:  0.6.  F.  O.  A  1'ophtalmoscopique 
on  ne  voyait  pas  bien  l'aure"ole.  Au  centre  de  macula  il  existait  un  petit 
point  rouge  sous  la  forme  d'un  petit  cone  de'coupe'.  Le  scotome  central  existe. 
0.  G.  normal. 


Troubles  Oculaires  Consecutifs  a  ^Observation  de  I'ficlipse     353 

06s.  No.  12. — S.  R.  A  fixe*  avec  1'oeil  droit  et  il  a  ferine*  son  oeil  droit 
strabique.  II  a  fixe  en  deux  fois  pendant  4-5  minutes.  Apres  la  seconde 
fixation  il  a  remarque*  une  tache  jaune  devant  son  oeil  droit.  Le  15  avril  a 
la  date  ou  nous  Favons  vu  pour  la  premiere  fois  son  oeil  droit  pre"sentait 
1'acuite*  visuelle  de  0.7.  La  tache  jaune  persiste.  F.  0.  normal.  Petit 
scotome.  0.  S.  Strabisme  convergent.  V.:  0.5.  Pas  de  tache. 

20  aout,  1921.  O.  D.  Pas  de  scotome.  Pas  de  tache.  V.:  IF.  0. 
normal. 

06s.  No.  13. — S.  Y.  age"  de  12  ans.  A  fixe"  le  9  avril  l'e"clipse  solaire  pendant 
15  minutes  avec  1'oeil  gauche  tantot  nu  tant6t  a  travers  le  verre  fume".  Le 
lendemain  apres  la  fixation  il  a  remarque"  devant  son  oeil  gauche  une  tache 
jaune-verdatre.  Pendant  la  lecture  il  ne  voyait  pas  certaines  lettres  et  sur- 
tout  le  soir  quand  il  lisait  a  l'e"clairage  e'lectrique. 

13  avril.  II  est  venu  pour  la  premiere  fois  a  la  consultation  chez  nous. 
0.  G.  V.:  0.4.  Scotome  existe.  La  tache  persiste.  F.  0.  Au  centre  de 
macula  une  tache  presque  noire,  avec  deux  petits  points  jaunatres  au  centre. 
0.  D.  normal. 

06s.  No.  14- — T.  P.  age"  de  20  ans.  A  fixe"  le  9  avril  avec  0.  D.  pendant 
une  heure  avec  interruption  tantot  a  1'oeil  nu  tantot  a  travers  le  verre  fume". 
Aussitot  il  a  remarque  devant  son  oeil  droit  une  tache  rouge,  le  lendemain 
cette  tache  est  devenue  violace*e  et  le  13  avril  le  jour  ou  il  est  venu  chez  nous 
pour  la  premiere  fois  cette  tache  e"tait  de  couleur  jaune.  0.  D.  V.:  0.7-0.8. 
F.  0.  aurdole  de  la  macula  tres  pale.  Au  centre  de  la  macula  une  tache  en  forme 
de  bague  avec  un  petit  point  jaune  au  centre.  Scotome  existait.  Pendant 
la  lecture  le  malade  ne  voyait  pas  les  mots  entiers. 

1  Sept.    Sans  changement. 

06s.  No.  15. — B.  M.  e"leve  au  Lycee,  age*  de  18  ans,  a  fixe"  le  9  avril  a  travers 
le  verre  fume",  puis  avec  1'oeil  droit  nu  pendant  10  minutes.  Le  meme  jour 
il  a  remarque"  devant  son  oeil  droit  une  tache  jaune  pale.  En  lisant  il  ne 
voyait  pas  certaines  lettres.  Le  19  avril  nous  1'avons  vu.  0.  D.  F.  0.  Au  centre 
de  la  macula  une  petite  tache  rouge  sous  le  point  jaune  au  centre.  Scotome 
paracentral.  La  tache  qui  a  persiste"  devant  cet  oeil  est  moins  forte.  V.: 
0.8.  0.  G.  normal. 

06s.  No.  16.— M.  S.  e"leve  du  Lyce"e,  age"  de  13  ans,  a  fixe"  le  9  avril  1921 
l'e"clipse  solaire  pendant  15  minutes  avec  1'oeil  droit  nu.  Le  meme  jour  il  a 
remarque*  une  tache  noire  devant  cet  oeil ;  et  pendant  la  lecture  il  ne  voyait 
pas  certaines  lettres  du  mot. 

19  avril.  Le  jour  ou  nous  1'avons  vu  il  pre"sentait  les  symptomes  suivants: 
0.  D.  Scotome  existe.  F.  0.  Au  centre  de  la  macula  on  voyait  un  petit 
point  rouge.  Au  niveau  de  la  partie  supe"rieure  de  l'aure"ole  existait  un  point 
rouge  fence"  et  entre  ce  point  et  celui  du  centre  il  y  avait  deux  points  blancs. 
V.:  0.5.  0.  G.  normal. 
23 


354  DRAGOUTINE  KOSTITCH 

4  Octobre.  0.  D.  Scotome  persiste.  V.:  0.6.  F.  0.  Au  centre  de  la 
macula  un  point  blanc  au  dessous  duquel  on  voyait  une  tache  rouge  en  arc. 
La  lecture  est  possible.  O.  G.  normal. 

06s.  No.  17. — S.  V.  e"leve  du  Lyce*e,  age"  de  13  ans.  A  fixe"  le  9  avril  avec  les 
deux  yeux  nus  pendant  3  minutes.  Le  lendemain  il  a  remarque"  une  tache 
noire  devant  chaque  oeil  ce  qui  1'a  fait  venir  le  11  avril  a  la  consultation  chez 
nous.  0.  D.  Pas  de  scotome.  V. :  IF.  0.  On  n'a  remarque"  rien  d'anor- 
mal  a  1'ophtalmoscopie.  O.  G.  La  meme  chose  que  1'autre. 

25  avril.    Les  scotomes  subjectifs  ont  disparus. 

06s.  No.  18. — B.  K.  61eve  du  Lyce*e  age  de  12  ans  a  fixe"  le  9  avril  avec  les 
deus  yeux  nus  pendant  une  demi  heure.  Le  meme  jour  il  a  remarqu6  devant 
Poeil  gauche  une  tache  verdatre.  Le  14  avril  jour  ou  nous  1'avons  vu  pour  la 
premiere  fois.  O.  G.  A  la  sciascopie  —2  D.  Scotome  central  existait. 
V.:  0.1.  Avec  la  correction  de  +2  D.  1'acuite"  e"tait  de  0.4.  La  tache  e"tait 
si  grande  qu'elle  1'empechait  de  voir  plusieurs  lettres  du  mot.  F.  O.  Dans 
un  petite  veine  qui  passe  en  dessus  de  la  macula  a  1 'image  ren verse"  on  remar- 
quait  un  petit  noeud.  Toute  la  region  maculaire  oedemacie*.  A  la  partie 
supe"rieure  du  centre  de  la  macula  il  existait  une  petite  tache  de  la  couleur 
framboise. 

0.  D.  e'mme'trope.  V.:  1.  F.  0.  normal.  II  n'est  plus  revenu  a  la  con- 
sultation. 

06s.  No.  19. — P.  K.  e"l(;ve  du  Lyce"e  age"  de  14  ans  a  fixe"  avec  I'oeil  droit 
pendant  plus  d'une  demi  heure.  Nous  1'avons  vu  le  lendemain  de  1'^clipse. 
II  se  plaignait  que  cet  oeil  avait  des  larmoiements  et  en  meme  temps  d'avoir 
du  sable  sous  les  paupieres  et  en  parti culier  sous  les  paupieres  superieures. 
O.  D.  Conjonctivite  sub  aigue.  Cette  conjonctivite  1'empechait  de  remar- 
quer  la  tache  noire  habituelle  chez  ce  genre  de  malades,  mais  apreis  la  gue"rison 
de  la  conjonctivite,  la  tache  noire  est  apparue.  V.:  0.9.  F.  O.  la  region 
maculaire  un  peu  rougeatre.  Pas  de  scotome.  0.  G.  normal.  II  n'est  plus 
revenu  a  la  consultation. 

06s.  No.  20. — J.  K.  e"leve  du  Lyce"e,  age"  de  11  ans,  a  fixe"  avec  I'oeil  droit  nu 
pendant  5  a  6  minutes.  Une  heure  et  demi  apres  la  fixation  il  a  remarqu6 
une  esp6ce  de  brouillard  jaunatre.  Ce  brouillard  comme  une  toile  d'ar- 
raigne"e  1'empechait  de  lire.  Le  lendemain  de  la  consultation  il  est  revenu  de 
nouveau  chez  nous.  Nous  1'avons  constate"  a  la  sciascopie  une  myopie  de 
5.0  aux  deux  yeux  0.  D.  V. :  apres  la  correction  0.6.  F.  0.  Dans  la  region 
maculaire  oedemacie".  Scotome  central.  Le  brouillard  persiste.  0.  G. 
myopie  de  5.0.  V.:  apres  la  correction:  1.  F.  0.  normal. 

25  avril.    Aucun  changement. 


Troubles  Oculaires  Consecutifs  d  I 'Observation  de  I'Bclipse      355 

CONCLUSIONS 

1.  L'observation  de  1'eclipse  solaire  du  9  avril  1921  a  Belgrade  a 
provoque  chez  les  curieux  qui  ont  fixe  1'eclipse  avec  les  yeux  nus  des 
troubles  oculaires,  forts  chez  les  uns,  plus  faibles  chez  les  autres. 

2.  II  est  caracteristique  que,  de  nos  20  malades,  19  sont  des  e"l£ves 
des  Lycees  de  Belgrade. 

Avant  1'eclipse,  les  ryceens  de  Belgrade  etaient  prevenus  du  danger 
que  courent  leurs  yeux  s'ils  ne  prenaient  pas  les  precautions  neces- 
saires,  qui  ont  ete  explique"es  par  nous  et  par  leurs  professeurs. 

3.  Nous  croyons  que  les  eleives,  empeches  de  lire  par  des  eblouisse- 
ments  provoques  par  scotome,  sont  venus  immediatement  consulter 
le  me'decin,  tandis  que  les  autres  malades  qui,  surtout  chez  les  paysans, 
croyaient  que  ce  n'etaient  que  des  troubles  passagers,  ne  sont  pas  venu 
consulter  le  medecin. 

4.  Les  lesions  oculaires  provoquees  par  la  fixation  de  l'6clipse  solaire 
peuvent  etre  faibles  ou  tres  fortes. 

5.  Le  symptome  le  plus  habituel  chez  ces  malades  est  le  scotome 
helioplegicum  ou  helieclipticum. 

6.  II  semble  que  les  rayons  lumineux  directs  du  soleil  sont  les  plus 
nuisibles. 

7.  Les  yeux  emmetropes  sont  plus  exposes  aux  accidents  pendant  la 
fixation  que  les  yeux  myopes  ou  hypermetropes. 


BIBLIOGRAPHIE 

1.  Holden:  Verres  pour  observer  le  Soleil,  Academic  de  medecine  de  New  York, 

1900. 

2.  Dr.   Klykoff:    Keratitis  Solaris  exfoliativa,  Wiestnik    Ophtalmologyi,   1904, 

xxi. 

3.  Zirm:  Ein  Fall  von  bleibenden  ausgedehnten  Veranderungen  der  beiden  Macu- 

lae durch  direktes  Sonnenlicht,  Graefe's  Arch.,  1905,  Ix,  3. 

4.  Sgrosso:  Su  d  una  diversita  di  Tinzione  che  osservasi  nelle  retine  di  rane  tenuta 

alia  oscurita  e  alia  luce  e  trattate  col  triacido  di  Ehrlich,  Archivio  di  ottal- 
mologia,  1906,  5-6. 

5.  Cohen:  tlber  den  Einfluss  des  Lebensalters  auf  die  Adaption,  Klinische  Mo~ 

natsblatter  fiir  Augenheilkunde,  Februar-Marz,  1906. 

6.  Marc  Dufour  et  J.  Gonin:   Eblouissement  de  la  retine,  Encyclopedic  fr.  d. 

opht.,  1906,  vi. 

7.  Bossalino:   Ancora  una  parolla,  sulla  visibilita  dei  raggi,  Annali  di  ottalmol., 

1907,  Fasc.  5. 

8.  Coats:   The  Pathology  of  Macular  Holes,  Royal  London  Ophth.  Hosp.  Re- 

ports, 1907,  xvii. 


356  DRAGOUTINE  KOSTITCH 

9.  Cords:    tlber  die  Verschmelzungsfrequenz  bei  periodischer  Netzhautreizung 
durch  Licht  oder  elektrische  Strohme,  Graefe's  Archiv,  1907,  Ixvii,  1. 

10.  H.  Villards:  Troubles  oculaires  conse"cutifs  a  1' observation  directe  des  eclipses 

du  Soleil,  Annales  d'Oculistique,  Aout,  1907,  cxxxvi. 

11.  Aubaret:  Sur  les  scotomes  par  eclipse  solaire.     Scotoma  helieclipticum,  Arch. 

d'ophtal.,  Fevrier,  1907. 

12.  Casali:  Ambliopia  consecutiva  e  fissazione  del  sol,  Annali  di  ottalmol.,  1907, 

Fasc.  3-4. 

13.  Lazareff :  Trois  cas  de  retinite  dans  la  region  de  la  macula  suvernus  a  la  suite  des 

e"ffets  des  rayons  directs  du  soleil  pendant  la  fixation  a  1'oeil  nu  de  1 'eclipse 
solaire  etun  cas  de  m^me  maladie  d 'origine  traumatique,  Wiestnik  Ophtal. 
mologyi,  1912,  xxix,  No.  7-8. 

14.  Vostrotine:    Un  cas  de  retinite  consecutif  a  la  fixation  de  1'eclipse  solaire, 

Roussky  Vratch,  1912,  No.  19. 

15.  Cords:   Sonnenblendung,  Zeitschr.  f.  Augenheilk.,  Juni,  1912. 

16.  Hoppe:    Augenscheidigung  durch  die  Sonnenfinsternis  am  17.  April,  1912. 

Munch,  med.  Wochenschr.,  1912,  No.  45. 

17.  Uhthoff:   Zu  zentraler  Blendungs-Retinitis  bei  Beobachtung  der  Sonnenfin- 

sternis am  17.  April,  1912,  Klin.  Monatsbl.  f.  Augenheilk.,  September,  1912. 

18.  Kaz:  Schadigungs-Veranderungen  des  Bulbusabschnittes  durch  Beobachtung 

der  Sonnenfinsternis,  Wochensch.  f.  Therapie  und  Hygiene  des  Auges, 
1912,  No.  10. 

19.  Birch-Hirschfeld:   Zum  Kapitel  der  Sonnenblendung  des  Auges,  Zeitschr.  f. 

Augenheilk.,  Oktober,  1912. 

20.  Strachoff:  Les  troubles  oculaires  survenus  d  la  suite  de  1' Eclipse  solaire  de  4 

Avril,  1912.  V.O.,  1913,  xxx,  iv,  No.  3. 

21.  Blessigue:  A  propos  des  troubles  oculaires  survenus  a  la  suite  de  la  fixation 

de  1'eclipse  solaire  le  4  Avril,  1912.  V.  O.,  1913,  xxx,  iv,  1. 

22.  Szafinski:  Scotoma  helioplegi  um  Postep  okylistyczny,  Giepec,  Sierpien,  1913. 


DISCUSSION 

COL.  R.  H.  ELLIOT  (London,  England) :  I  saw  a  good  deal  of  eclipse  blindness 
in  India,  and  would  like  to  mention  some  additional  causes  which  are  not 
mentioned  in  the  paper.  One  is  the  reflection  of  light  from  water  when  a 
boat  is  being  steered  in  the  sun's  eye  on  a  tropical  sea  or  river;  another  is 
taking  observations  by  the  sextant  at  sea;  a  third  is  a  religious  rite  of  the 
Brahmins :  Every  orthodox  Brahmin  has  to  cross  his  hands  and  look  through 
them  at  the  sun  at  certain  times  of  day.  I  understand  a  number  of  them  do 
not  trouble  to  look  at  the  sun,  but  look  through  a  wall  on  which  the  sun 
shines;  but  a  number  do  really  look  at  the  sun,  and  Col.  Kirkpatrick  has 
described  eclipse  blindness  as  a  result  of  this  rite.  The  practice  of  observing 
an  eclipse  through  a  pail  of  water  is  common  in  the  Tropics,  and  is  extremely 
dangerous.  It  may  lead  to  very  definite  eclipse  blindness. 

Some  little  time  ago  I  saw  an  officer  of  the  Indian  Government  who  had 
ridden  a  long  distance  besides  rice  fields  in  the  early  morning.  The  sun  came 
obliquely  through  the  rice  fields  to  his  eyes,  and  when  he  came  to  me  after- 
ward he  had  a  well-marked  eclipse  scotoma. 


Troubles  Oculaires  Consecutifs  a  V Observation  de  I' Eclipse     357 

An  interesting  point  in  Dr.  Kostitch's  paper  is  the  youth  of  the  subjects, 
because  the  opinion  hitherto  held  by  ophthalmologists  is  that  it  is  rare  to  find 
eclipse  scotoma  in  young  people. 

A  point  I  do  not  find  referred  to  is  the  association  of  eclipse  scotoma  with  a 
ring  scotoma  lying  between  35  degrees  to  50  degrees  in  the  field.  This  has 
been  noticed  both  in  aviators  and  in  those  who  have  had  to  do  with  anti- 
aircraft guns. 

Another  extraordinary  thing  in  this  paper  is  the  number  of  people  in  whom 
both  eyes  are  affected,  because  past  experience  would  seem  to  indicate  that 
most  of  the  patients  had  involvement  of  only  one  eye. 

There  is  a  practical  point  I  would  like  to  call  attention  to  in  the  differential 
diagnosis  from  hysteria.  Scotoma  due  to  sun-blindness  is  small;  at  twenty 
feet  away  it  just  covers  the  face.  I  recently  saw  a  girl  who  had  looked  at  the 
sun,  and  believed  she  had  central  scotoma,  but  her  scotoma  covered  the  whole 
subject  standing  a  few  feet  away.  That  was  obviously  not  a  central  scotoma, 
as  the  subsequent  history  proved.  Another  point  in  hysterical  cases  is  that 
the  scotoma  does  not  necessarily  appear  immediately  after  the  exposure  to 
the  sun,  whereas  in  the  real  cases  the  patients  give  a  history  of  a  scotoma 
coming  on  at  once. 

A  point  about  prophylaxis.  The  best  way  to  look  at  a  sun  eclipse  is  first  to 
use  a  negative  which  has  been  suitably  exposed  to  light  and  fully  developed 
so  as  to  get  a  uniform  dark  plate;  and  second,  to  avoid  looking  at  the  sun  for 
any  prolonged  period.  It  is  the  prolonged  looking  at  the  sun  that  does  the 
mischief.  Another  point  is  to  do  what  certain  countries — Sweden,  for 
instance — have  done,  and  to  start  a  press  campaign  before  each  eclipse  warn- 
ing people  of  the  dangers  involved  in  looking  at  the  sun,  telling  them  how 
they  may  safely  and  comfortably  view  the  eclipse. 

DR.  GEORGE  MACKAY  (Edinburgh,  Scotland) :  The  subject  under  discus- 
sion attracted  my  attention  many  years  ago.  The  writer  of  today's  paper 
has  limited  his  survey  of  the  literature  to  the  period  of  1900  to  1912,  which 
makes  me  feel  somewhat  antediluvian,  because  my  paper  was  written  in  1894, 
and  has  not  received  Dr.  Kostitch's  attention.  However,  I  am  somewhat  to 
blame  because  the  title  of  my  paper  did  not  indicate  that  it  had  reference  to 
eclipse  blindness,  it  being  entitled  "Blinding  of  the  Retina  by  Direct  Sun- 
light." It  so  happens  that  a  majority  of  cases  of  retinal  damage  from  solar 
rays  do  arise  after  gazing  at  an  eclipse,  but  I  venture  to  think  that  my  title  is 
more  correct,  since  this  damage  may  happen  at  any  time  if  an  observer  directs 
his  gaze  to  the  sun's  face.  My  paper  contained  a  complete  survey  of  the 
literature  so  far  as  I  knew  up  to  1894.  I  was  about  to  make  a  fresh  survey  of 
the  whole  literature  of  the  subject  about  1912,  as  I  thought  a  sufficient 
interval  had  elapsed,  but  just  then  there  appeared  a  paper  written  by  a 
German,  a  monograph  presented  I  think  as  a  thesis  at  one  of  the  German 
universities,  and  it  so  completely  covered  the  ground  that  I  set  to  work  to 
translate  that  rather  than  prepare  a  new  paper. 

I  have  already  pointed  one  moral,  namely,  that  if  you  want  to  attract  the 
public  eye  you  must  be  careful  what  title  you  employ,  for  my  paper  has  been 
frequently  overlooked. 


358  DRAGOUTINE  KOSTITCH 

Another  point  I  would  like  to  make  is  this:  I  would  most  respectfully  sug- 
gest to  the  organizers  of  meetings  such  as  this  that  before  they  put  out  a 
pre-session  volume  they  should  endeavor  to  anticipate  that  by  a  still  earlier 
pre-session  list  of  the  titles  of  the  papers  which  will  be  discussed.  That  could 
be  sent  out  before  the  full  contents  of  the  papers  are  set  up  in  print.  Those 
who  have  come  from  a  distance  are  at  a  great  disadvantage  in  being  unin- 
formed before  leaving  home  as  to  the  subjects  to  be  discussed.  I  must  make 
apology,  therefore,  which  is  not  altogether  my  own  fault,  that  I  cannot 
remember  the  name  of  the  writer  of  that  important  paper,  but  it  will  un- 
doubtedly be  found  in  the  Index  Medicus  about  the  years  1912  or  1913.  It 
is  a  most  admirable  monograph,  bringing  the  literature  up  to  that  date. 

There  are  one  or  two  points  to  which  reference  has  not  been  made  by  Dr. 
Kostitch,  and  on  which  I  should  like  to  have  had  his  opinion  had  he  been 
here.  One  symptom  to  which  he  does  not  refer,  but  which  many  have 
observed,  is  a  quivering  movement  complained  of  by  the  patient.  What  is 
that  due  to?  It  passes  away  in  many  cases,  but  it  is  often  persistent.  In 
fact,  in  one  case,  that  of  a  medical  colleague,  it  is  the  only  thing  he  still  feels, 
although  the  accident  happened  a  quarter  of  a  century  ago.  I  suggest  that 
whereas  the  normal  stimulus  of  moderate  light  only  excites  molecular  or 
atomic  vibrations  in  retinal  cones  and  rods,  the  more  violent  assault  of  fo- 
cussed  sunlight  loosens  the  attachment  of  some  of  the  cells  to  one  another  so 
that  a  whole  cell  vibrates  separately  or  in  groups. 

Another  question  is  as  to  whether  the  injury  is  produced  by  the  concentra- 
tion of  the  light  rays  or  from  the  heat  rays.  One  is  inclined  to  think  that 
it  is  more  probably  the  light  rays  than  the  heat  rays.  That  is  a  point  upon 
which  I  should  be  glad  to  have  had  some  information. 

Another  point  upon  which  I  especially  endeavored  to  start  inquiry  in  my 
communication  of  1894  has  reference  to  the  prognosis.  Recently  a  book  was 
sent  me  for  review,  "Medical  Ophthalmology,"  by  Dr.  Foster  Moore,  and  I 
am  gratified  that  he  has  reproduced  the  tentative  conclusions  which  I  put 
forward  in  1894.  It  appeared  to  me  that  here  we  had  an  illustration  of  the 
most  exact  injury  to  the  human  tissues  which  it  was  possible  to  produce  by 
purely  physical  methods;  an  injury  to  a  part  which  is  beyond  external  con- 
tamination by  septic  influence.  Moreover,  the  injured  part  can  give  expres- 
sion to  the  extent  and  intensity  of  the  damage  received,  and  continued 
observations  afford  a  very  exact  method  of  indicating  the  prognosis,  depend- 
ent upon  the  nature  and  extent  of  the  primary  injury  and  the  time  elapsing 
since  it  was  received.  The  basis  for  deduction  is  broadened  if  there  is  any 
record  of  the  vision  prior  to  the  sun  blinding.  Therefore  what  I  endeavored 
to  lay  down  was  this,  based  upon  the  results  up  to  1894.  I  defined  the  term 
"practical  recovery"  as  meaning  the  "cessation  of  obtrusive  defect"  which 
leaves  the  patient  unconscious  of  having  received  damage.  I  was  able  to 
classify  the  cases  into  four  groups.  Taking  direct  acuteness  of  one-third  of 
Snellen's  type  as  the  starting  point,  the  patient  with  one-third  vision  in  the 
first  week  has  a  good  chance  for  practical  recovery  in  one  month;  the  patient 
with  one-third  vision  in  the  second  week  has  a  good  chance  for  practical 
recovery  in  three  or  four  months;  the  patient  with  one-third  vision  in  the 
third  week  has  good  chance  for  practical  recovery  in  five  or  six  months,  but 


Orbital  Marsupialization  359 

if  the  vision  at  any  time  is  less  than  one-third  of  the  normal  there  is  a  very 
poor  chance  of  ever  recovering  six-sixths.  I  venture  to  hope  that  these 
suggestions  may  be  pursued  and  confirmed  or  corrected. 

DR.  F.  M.  FERNANDEZ  (Havana,  Cuba) :  With  each  new  eclipse  the  number 
of  cases  of  retinal  lesions  becomes  less  and  less.  This  is  due  in  Cuba  to  the 
extensive  warnings  that  are  published  in  the  daily  papers. 

Some  few  cases  of  solar  retinitis  have  been  observed  in  Cuba  in  the  past 
fourteen  years.  Symptoms  have  been  moderate  in  the  majority  of  the  cases — 
central  and  para-central  scotoma,  diminution  of  visual  acuity,  and  so  forth. 
There  have  been  observed  two  cases  of  retinal  detachment  after  prolonged 
observation  of  the  eclipse,  one  of  them  in  a  myopic  eye.  This  detachment  has 
also  been  observed,  without  any  eclipse,  by  prolonged  exposure  to  the  sun's 
rays.  This  last  case  was  observed  by  Dr.  Santos  Fernandez  and  myself  in  a 
gentleman  who  was  a  spectator  at  the  Willard-Johnson  fight  in  Havana  years 
ago,  and  who,  after  being  three  or  four  hours  exposed  to  the  direct  solar  rays, 
had  a  total  detachment  of  the  retina  in  one  eye. 

MR.  J.  GRAY  CLEGG  (Manchester,  England) :  I  would  like  to  emphasize 
the  wisdom  of  what  Dr.  Mackay  suggests  about  a  list  of  subjects  to  be  dis- 
cussed. I  was  personally  unaware  until  I  arrived  here  just  what  was  coming 
up.  I  shall  only  mention  a  case  which  is  referred  to  in  a  letter  that  I  received 
two  days  ago..  A  little  boy  got  some  glass  in  one  eye  and  as  a  result  had 
sympathetic  disease.  He  had  recovered  from  the  sympathetic  disease  with 
perfect  acuity,  but  had  another  attack  of  iridocyclitis  six  months  ago.  During 
my  absence,  a  fortnight  ago,  he  looked  at  an  eclipse  of  the  sun,  and  a  rather 
severe  recrudescence  has  resulted. 


ORBITAL  MARSUPIALIZATION  AND   SUPERIORITY 

OF  ORGANIC  GRAFTS  OF  DEAD  TISSUE  IN 

ESTABLISHING  A  MOBILE  STUMP 

DR.  A.  MAGITOT 

Paris,  France 

Since  the  year  1885,  in  which  Mules  proposed  enclosing  a  glass 
sphere  in  the  sclerotic  in  order  to  create  a  mobile  stump,  numerous 
authors  have  repeated  the  operation.  The  question  was  also  dis- 
cussed in  many  scientific  meetings,  and  particularly  in  1900  at  the 
International  Congress  of  Paris.  It  would  seem  that  it  might  be 
treated  anew  in  order  to  determine  the  results  obtained  by  clinical 
practice.  Moreover,  during  the  last  few  years  experimental  re- 
searches on  grafts  of  dead  tissue  have  brought  fresh  data  by  which 
ophthalmologists  should  profit  in  their  choice  of  the  substance  to  be 
inserted  in  the  funnel  of  the  ocular  muscles. 


360  A.  MAGITOT 

Though  making  no  pretension  to  writing  the  history  of  the  ques- 
tion, we  think  that  it  is  necessary  to  recall  the  successive  stages  fol- 
lowed by  the  different  operators.  Mules,  in  1884,  had  at  the  same 
time  as  v.  Graefe,  proposed  the  amputation  of  the  anterior  segment 
and  the  evisceration  of  the  eyeball  in  all  cases  in  which  total  extirpa- 
tion could  be  avoided.  In  1885  he  proposed  enclosing  in  the  sclerotic 
a  glass  ball;  in  the  following  years,  Brudnell  Carter,  A.  Frost,  Grims- 
dale,  Lang,  Kroll  and  Cross,  Bickerton,  Swanzy  in  England,  L.  W. 
Fox  and  Orax,  Reeve,  de  Schweinitz,  and  Buller  in  America,  experi- 
mented with  the  new  process.  The  enclosure  of  a  glass  sphere  in 
the  Tenon  capsule  was  also  tried ;  later  on  numerous  substances  were 
proposed — rubber  (Pick),  celluloid  (Lang),  paraffin  wax  (Hepburn), 
asbestos  (Claiborne),  the  pith  of  the  elder  tree  (Elschnig),  etc.  But 
the  preference  of  the  authors  was  for  precious  metals.  Kuhnt  (1887) 
had  enclosed  silver  spheres  in  the  sclerotic,  but  two  years  later  Wagen- 
mann  had  occasion  to  study  some  of  his  stumps  and  came  to  the  con- 
clusion that  dangerous  inflammatory  reactions  might  be  produced. 
Operators  then  returned  to  spheres  in  platinum  and  particularly  in 
gold.  We  know  that  many  American  ophthalmologists  have  made 
use  of  this  substance  and  that  certain  of  their  patients  have  preserved 
a  mobile  stump  for  many  years. 

Today,  twenty-six  years  after  Mules's  communication,  we  are  able 
to  measure  the  ground  covered.  To  judge *by  the  results  obtained 
and  the  opinions  published,  it  seems  that  many  ophthalmologists 
are  agreed  to  attempt  to  make  a  mobile  stump  in  all  cases  where 
there  is  no  orbital  infection.  Some  are  in  favor  of  evisceration  with 
inclusion  of  a  glass  or  gold  ball;  others,  fearing  sympathetic  ophthal- 
mia, prefer  extirpation  and  planting  a  sphere  in  the  Tenon  capsule. 
These  two  methods  constitute,  in  fact,  a  part  of  the  foundations  on 
which  rests  the  problem  to  be  solved.  The  other  part  is  constituted 
by  the  choice  of  the  substance  to  be  enclosed. 

If  we  are  to  judge  by  the  number  of  ill-assorted  substances  which 
have  been  employed,  this  second  part  of  the  problem  is  not  the  least 
important.  Many  substances  have  not  given  satisfaction,  others  are 
heavy,  others  are  rare  and  costly.  Those  which  have  been  employed 
most  often  are  glass  and  gold,  as  being  the  ones  producing  the  mini- 
mum of  painful  or  inflammatory  reactions.  As  a  corollary,  it  is 
patients  operated  in  this  way  who  have  most  frequently  been  pre- 
sented in  scientific  societies. 

However,  for  an  operation  not  to  have  come  into  universal  use,  in 


Orbital  Marsupialization  361 

spite  of  the  examples  of  wearers  of  gold  or  glass  spheres  who  had  been 
operated  ten  or  fifteen  years  previously,  it  must  have  aroused  some 
hesitation  and  distrust.  Many  hold  that  we  have  not  yet  emerged 
from  the  experimental  stage  and  leaving  to  others  the  onus  of  experi- 
menting, reserve  their  opinion  until  they  shall  be  convinced  of  the 
excellence  and  innocuousness  of  a  method. 

Indeed,  in  spite  of  a  few  cases  remarkable  for  their  duration  and 
the  esthetic  effect  obtained,  it  must  be  confessed  that  the  inclusion 
of  a  gold  or  glass  sphere  does  not  always  succeed.  Precocious  or 
tardy  expulsion  may  take  place,  when  the  operation  has  succeeded 
and  after  a  lapse  of  several  weeks ;  it  is  therefore  impossible  to  assert 
that  the  mobile  stump  will  be  permanent. 

ORGANIC  AND  INORGANIC  SUBSTANCES 

The  expulsion  of  a  gold  or  glass  sphere  may  take  place  shortly 
after  the  operation,  when  the  asepsis  has  not  been  perfect  or  when  an 
accident  occurs,  such  as  a  hematoma  which  distends  the  tissues  and 
brings  about  rupture  of  the  sutures.  But  this  expulsion  can  also  take 
place  several  years  later  as  if  there  had  been  a  sort  of  wearing  out  of. 
the  conjunctiva  which  covers  the  sphere.  This  tissue  gradually 
becomes  thinner,  a  small  orifice  appears  which  grows  progressively 
and  one  day  the  sphere  escapes  from  the  cavity  without  there  having 
been  properly  speaking  any  suppuration.  Such  an  accident  may 
supervene  just  as  well  with  other  inorganic  substances  such  as  ebonite, 
galite,  celluloid,  asbestos,  agar-agar,  etc. 

As  for  paraffin  wax,  injected  under  pressure  or  fashioned  into  a 
ball  (Brockart,  Camann,  M.  Ramsay,  Spratt),  it  likewise  has  caused 
many  disappointments.  Generally  speaking,  its  point  of  fusion  is 
too  low.  When  it  is  75°  C.  (like  that  used  by  Hertel),  its  superiority 
over  ebonite  lies  only  in  the  facility  with  which  the  operation  can 
give  it  the  desired  shape. 

It  was  certainly  for  the  purpose  of  obtaining  a  permanent  stump 
that  recourse  was  had  no  longer  to  an  inorganic  substance  but  to 
living  tissue.  Baraquez,  Velez,  Bartels,  Marx,  Lauber,  recom- 
mended the  use  of  fatty  tissue,  usually  taken  from  the  abdomen  of 
the  patient  and  enclosed  either  in  the  sclerotic  or  in  the  Tenon  cap- 
sule. This  method  has  been  repeated  sufficiently  often  these  last 
few  years  for  it  to  be  possible  to  judge  of  its  value.  The  results  of 
recent  operations  are  good,  those  of  long  standing  are  disappointing. 
As  Marx  has  noted  in  his  histologic  examinations,  the  graft  is  re- 


362  A.  MAGITOT 

absorbed  and  the  stump  becomes  of  insignificant  volume.  In  1912 
Sattler,  in  1914  Carlotti  and  Bailleul  tried  successfully  on  man  the 
graft  of  living  costal  cartilage,  but  the  long-standing  results  of  their 
transplantations  have  remained  unknown.  In  1915,  I  in  my  turn 
tried  this  method  on  men  wounded  in  the  war,  and  I  was  able  to  con- 
vince myself  that  it  offered  many  serious  inconveniences.  First  of 
all  must  be  placed  the  extreme  sensitiveness  of  this  tissue  to  infection 
and  in  consequence  of  this  frequent  premature  eliminations.  Sec- 
ondly, living  cartilaginous  tissue,  like  fatty  tissue,  is  absorbed  in  a 
few  months.  This  disappearance  is  the  more  rapid  as  the  thin  and 
flat  human  costal  fragment  is  far  from  being  sufficiently  voluminous 
to  constitute  (even  in  the  beginning)  a  good  stump. 

We  shall  merely  make  a  passing  mention  of  the  living  heteroplastic 
grafts  of  dog's  or  cat's  eyes  (Lagrange,  Rohmer,  Boiadjeff)  whose 
atrophic  evolution  is  similar  and  we  shall  now  speak  of  a  very  inter- 
esting category  of  substances:  we  refer  to  dead  organic  transplan- 
tations. 

Belt,  shortly  after  Mules's  communication,  had  the  idea  of  im- 
planting in  the  Tenon  capsule  a  piece  of  sponge,  following  in  this  a 
study  of  Hamilton's  which  appeared  in  1881.  Hamilton  had  re- 
peated experiments  already  made  by  Strieker  (of  Vienna)  consisting 
in  keeping  under  supervision  the  evolution  of  aseptic  sponges  intro- 
duced into  the  peritoneum  of  laboratory  animals.  He  had  noted 
that  the  framework  of  the  sponge  served  as  guides  for  the  vessels 
to  fresh  connective  tissue  and  that  at  the  end  of  a  certain  time  the 
organism  completely  incorporated  this  exogenous  tissue.  Belt's 
experiment  was  renewed  by  Trousseau  and  by  Valude,  these  opera- 
tions were  not  successful:  elimination  took  place  in  the  first  few  days. 
Much  more  favorable  were  the  attempts  of  Schmidt  (1910)  who 
made  use  of  globes  of  bone  sterilized  by  steam.  There  was  no  elimina- 
tion and  the  stump  kept  its  primitive  dimensions.  De  Wecker  and 
Kuhnt  also  obtained  favorable  results  with  sterilized  bone;  and  if 
this  method  has  not  become  more  universal,  it  is  probably  due  to  the 
difficulty  of  finding  spheres  cut  to  the  necessary  dimensions  (fifteen 
to  twenty  millimeters  in  diameter)  and  ready  for  use. 

In  1915,  having  had  disappointments  in  attempting  to  graft  living 
costal  cartilage  in  the  Tenon  cavity,  I  had  the  idea  of  practising  on 
wounded  soldiers  inclusions  of  calf  cartilage  fixed  in  formalin  of  20% 
for  a  week,  and  then  carefully  washed.  My  intention  was  to  proceed 
by  two  stages.  First  to  make  an  inclusion  of  dead  cartilage,  pre- 


Orbital  Marsupialization  363 

liminary  operation,  whose  object  was  to  avoid  elimination  of  the  living 
cartilage  which  is  so  sensitive  to  infection.  I  desired  in  this  way  to 
get  over  the  dangerous  period  and  three  months  later  to  remove  the 
temporary  inclusion  and  graft  in  its  place  costal  cartilage,  which 
according  to  my  idea,  was  to  form  a  permanent  stump. 

The  insertions  of  formalinized  cartilage  were  successful,  but  my 
astonishment  was  great  on  finding  that  after  several  trials  the  living 
transplant  rapidly  diminished  in  volume  whereas  the  first  had  not 
varied.  I  therefore  modified  my  mode  of  operation  and  systematic- 
ally employed  in  all  cases  of  extirpation  inclusions  of  formalinized 
cartilage.  In  1917  I  presented  to  the  Paris  Ophthalmological  So- 
ciety a  number  of  patients  operated  since  twelve  months.  In  1918 
I  presented  some  more,  but  I  published  no  monograph  on  the  subject, 
wishing  to  submit  the  process  to  the  proof  of  time.  Today  after  six 
years'  practice,  and  an  experience  of  sixty  cases,  I  can  speak  with  a 
full  knowledge  of  the  subject.  In  the  meanwhile  researches  on 
grafts  have  made  clear  certain  obscure  points.  They  have  brought 
to  light  certain  biologic  conditions  which  it  is  indispensable  to  know. 

TRANSPLANTS  OF  DEAD  TISSUE 

For  a  very  long  time  it  was  believed  that  only  living  tissue  could  be 
grafted,  that  is  to  say  once  transplanted  they  were  accepted  by  their 
host's  organism,  and  that  they  continued  to  live  on  their  own  account. 
All  that  was  known  was  that  the  chances  of  success  were  slight,  and 
that  even  under  the  most  favorable  conditions  (autoplasty)  there 
were  for  grafts  without  pedicle  about  40%  of  failures.  In  the  years 
following  the  great  war,  a  considerable  number  of  prosthetic  opera- 
tions were  attempted  on  the  limbs,  radiographic  examinations  were 
multiplied,  experimental  studies  were  carried  out  and  it  was  dis- 
covered that  the  vascular,  osseous,  tendinous  or  nervous  grafts  which 
appeared  to  be  really  living,  in  reality  died  a  short  time  after  their 
transplantation.  But,  and  it  is  of  capital  importance,  it  was  re- 
marked that  simultaneously  their  carcass  served  as  a  framework  for  a 
young  tissue,  the  newly  formed  cells  of  which  took  the  place  of  those 
of  the  transplant.  This  phenomenon  occurs  on  condition  that  there 
be  contact  between  the  graft  and  the  tissue  of  similar  nature  of  the 
organism  of  the  host. 

Here  is  therefore  a  new  conception  of  living  grafts  which  revolu- 
tionizes our  old  ideas  and  explains  the  bad  results  obtained  by  trans- 
plantation into  the  orbit  of  living  cartilage.  It  is  a  sort  of  biologic 


364  A.  MAGITOT 

law  to  which  the  only  exceptions  appear  to  be  the  cutaneous  epi- 
thelium and  the  corneal  epithelium. 

But  if  all  living  tissue  (nerve,  bone,  cartilage,  tendon)  dies,  it  must 
be  remembered  that  its  presence  suffices  to  provoke  the  appearance 
of  young  cells  of  the  same  nature,  and  it  comes  to  mind  immediately 
that  a  transplantation  of  dead  tissue  ought  to  provoke  the  same 
phenomenon.  Experiments  have  shown  that  this  is  so,  and  that 
nerves,  tendon  or  bone  killed  by  alcohol  or  formalin,  fulfilled  quite 
as  well  and  even  better  their  role  as  framework  for  the  new  tissue. 
These  facts  explain  Hamilton's  remark,  which  we  have  previously 
mentioned,  and  enable  us  to  understand  how  an  aseptic  sponge  can 
be  invaded  by  connective  tissue.  For  the  same  reason  we  can  no 
longer  feel  astonished  at  the  good  results  obtained  by  Schmidt  and  by 
Kuhnt,  in  making  use  of  bone  to  execute  Mules's  operation. 

Professor  Nageotte  (Paris)  has  likewise  shown  (1920)  how  the 
tissues  of  the  host  act  differently  with  an  inorganic  transplant,  such  as 
glass,  gold,  ebonite,  etc.,  and  with  a  transplant  of  organic  tissue  killed 
by  histologic  fixation. 

A  disk  of  glass,  silver  or  of  rubber,  inserted  under  the  skin  of  a 
rabbit's  ear,  causes  no  reaction  of  the  tissue:  it  encysts  and  the 
membrane  of  this  cyst  is  itself  insignificant.  If  the  pocket  be  opened, 
the  foreign  body  will  be  found  there  in  a  state  of  liberty.  The  result 
is  quite  different  if  we  insert,  in  the  same  place,  a  disk  of  bone  or 
cartilage  previously  fixed  in  alcohol  or  formalin,  that  is  to  say,  a  disk 
of  substance  organized  but  deprived  of  life.  Union  almost  immedi- 
ately takes  place  by  continuity  of  substance  between  the  inserted  piece 
and  the  connective  tissue  of  the  host.  In  the  case  of  cartilage  this 
adherence  takes  place  through  the  perichondrium.  In  the  case  of 
dead  bone  an  analogous  phenomenon  occurs.  The  natural  surfaces 
adhere  to  connective  substance  of  the  host,  but  neither  in  the  case 
of  cartilage  nor  of  bone  do  the  surfaces  of  section  join  with  it. 

Independently  of  this  union  between  dead  and  living  tissue,  a 
phenomenon  which  already  differentiates  entirely  the  inclusions  of 
organic  or  inorganic  substances,  there  appears  later  a  new  factor  of 
great  interest.  When  the  transplants  are  osseous  or  cartilaginous, 
there  appear  at  the  points  of  contact  of  the  dead  tissue  osseous  nodules 
or  again  cartilaginous  nuclei  produced  by  the  connective  tissue  of  the 
host.  It  follows  that,  at  the  end  of  a  certain  period  a  fresh  skeleton 
piece  is  formed  which  envelops  the  transplant.  The  latter  enveloped 


Orbital  Marsupialization  365 

in  a  living  sheath  will  persist  unless  young  living  tissue  substitute 
itself  for  it  progressively. 

From  these  facts,  we  now  know  that  when  introduced  into  the 
organism  organized  substances,  even  when  they  are  deprived  of  cells 
and  unable  to  be  re-inhabited,  take  up  once  more  a  role  in  the  life  of 
the  tissues.  We  have  at  the  same  time  the  explanation,  not  only  of 
the  perfect  toleration  of  dead  cartilaginous  or  osseous  fragments 
transplanted  into  the  orbit,  but  also  of  their  persistence  without 
diminution  in  volume. 

CARTILAGE  FIXED  IN  FORMALIN 

I  chose  cartilage  in  preference  to  bone  because  it  can  be  cut  as 
easily  as  a  potato.  The  sternal  piece  of  large-sized  calves  is,  however, 
the  sole  material  voluminous  enough  to  allow  the  cutting  out  of 
fragments  of  twenty  to  twenty-five  millimeters  in  thickness  and  of 
the  length  required.  One  should  be  very  careful  not  to  remove  the 
perichondrium,  as  this  membrane  will  be  the  point  of  union  between 
the  transplant  and  the  tissues  of  the  host.  This  fresh  cartilage  is 
fixed  during  eight  to  ten  days  in  a  solution  of  formalin,  20%.  The 
formalin  is  then  decanted  and  replaced  by  sterilized  water.  This 
substance  is  ready  for  use  two  weeks  later  when  it  has  had  time  to 
disgorge  the  fixing  product.  This  formalin  will  permeate  the  water 
and  in  this  weak  antiseptic  solution,  the  fragments  will  keep  inde- 
finitely, forming  a  reserve  on  which  one  can  draw  according  to  re- 
quirements. 

The  mode  of  operation  I  followed  is  very  simple.  After  extirpa- 
tion, the  fragment  is  inserted  into  the  muscular  funnel.  It  is  neces- 
saryjthat  hemostasis  should  be  complete.  The  edges  of  the  muscular 
plane  are  seized  with  small  clips  the  vertical  traction  of  which  keeps 
the  pocket  open.  The  fragment,  which  should  be  as  large  as  possible, 
is  then  pushed  into  the  bottom,  and  the  pocket  is  very  carefully 
sutured  with  catgut.  Over  this  muscular  layer  the  conjunctiva  must 
be  closed  with  U-shaped  stitches  so  as  to  make  sure  that  the  edges 
must  meet  perfectly.  I  terminate  the  operation  by  a  temporary 
blepharorrhaphia  which  I  suppress  on  the  third  day.  This  sealing  of 
the  eyelids  is  a  precautionary  measure  in  case  of  secondary  hemor- 
rhage which  would  distend  the  pocket.  Its  effect  is  to  prevent  the 
chemosis  which  often  results  from  the  rubbing  of  the  eyelashes  on  the 
conjunctiva. 


366  A.  MAGITOT 

The  patient  is  then  furnished  with  a  binocular  dressing  for  three 
days  in  order  to  immobilize  the  ocular  muscles. 

Since  1917  I  have  always  followed  this  same  technic  after  having 
assured  myself  of  its  perfect  efficacy. 

I  consider  as  essential: 

1.  The  suturing  of  the  muscles  and  of  the  conjunctiva  in  two  planes 
with  separate  stitches. 

2.  Complete  hemostasis. 

3.  The  inclusion  of  a  voluminous  cartilage  from  which  the  perichon- 
drium  must  not  have  been  scraped  off. 

4.  A  binocular  dressing  for  three  days. 

All  those  who  may  try  the  implantation  of  formalinized  cartilage 
by  this  method,  will  perceive  the  ease  with  which  the  organism  ac- 
cepts this  dead  tissue.  Except  in  the  case  of  panophthalmia  or  of 
orbital  infection,  recourse  may  be  had  to  it  and  I  have  had  numerous 
successes  after  extirpation  for  laceration  of  the  eyeball  by  projectiles 
of  war.  Elimination  in  the  first  days  will  only  take  place  if  there  is 
infection,  serious  hematoma  and  if  the  cartilage  has  been  deprived  of 
all  its  perichondrium.  But  if  there  is  no  elimination  in  the  first  fort- 
night, the  transplant  may  be  considered  as  permanent,  for  in  my 
cases  I  have  never  had  a  tardy  elimination. 

Dead  cartilage  offers  over  living  cartilage  the  great  advantage  of 
being  able  to  furnish  voluminous  fragments.  Whatever  its  origin 
may  be,  it  is  nevertheless  always  made  up  of  pieces  rather  long  and 
thick.  The  cross  section  is  at  the  two  extremities  whereas  the  other 
faces  are  covered  with  the  perichondrium.  When  inserting  the 
transplant  into  the  cavity,  I  proceed  so  that  the  sides  covered  with 
this  connective  sheath  may  be  in  contact  with  the  rectus  internus 
and  externus  muscles,  so  that  the  adherence  may  take  place  princi- 
pally with  the  muscles  which  control  the  horizontal  movements. 

MARSUPIALIZATION  AND  TRANSPLANTATION 

I  have  just  spoken  of  the  transplantation  of  formalinized  cartilages 
at  the  moment  of  extirpation.  This  operation  is,  however,  still  pos- 
sible in  cases  of  long-standing  extirpation  where  the  patients  are  not 
satisfied  with  their  immovable  stump.  The  only  conditions  required 
are:  a  clean  conjunctival  cavity  and  behind  a  small  mobile  cluster 
formed  of  retracted  muscles.  Briefly,  extirpation  must  have  been 
practised  in  a  proper  manner. 
The  problem  consists  in  creating  in  the  midst  of  the  fibromuscular 


Orbital  Marsupialization  367 

mass  at  the  bottom  of  the  orbit  a  pocket  (marsupialization),  in  the 
middle  of  which  will  be  inserted  the  fragment  of  cartilage.  This 
result  is  obtained  by  incising  and  then  freeing  the  conjunctiva  from 
its  deep  attachments. 

The  fibromuscular  mass  is  then  seized  by  its  center,  an  opening  is 
made  in  it,  and  this  is  enlarged  by  means  of  a  forceps.  The  edges 
are  drawn  forward  and  the  cartilaginous  transplant  is  pushed  in. 
The  muscles  are  then  sutured  with  catgut,  the  conjunctiva  with 
silk  and  we  terminate  by  a  blepharorrhaphia  as  in  an  ordinary  opera- 
tion. 

In  December,  1921,  I  presented  to  the  Ophthalmological  Society 
of  Paris  an  officer  who  had  been  obliged  to  undergo  the  operation  of 
extirpation  during  the  war.  Two  years  later,  immediately  after  the 
armistice,  he  came  to  see  me,  complained  of  his  immovable  stump, 
and  asked  me  to  remedy  it.  He  was  operated  in  February,  1919. 
The  consequences  of  the  operation  were  very  simple,  and  for  three 
years  he  has  been  wearing  a  movable  stump  which  has  not  diminished 
in  volume.  The  transplant,  which  is  very  large,  raises  the  eyelid 
well,  and  avoids  that  ugly  fold  which  cannot  be  prevented  in  ordinary 
enucleation. 

CONCLUSION 

The  superiority  of  inclusions  of  dead  organic  tissues  to  living 
tissues  is  established  by  clinical  practice.  When  the  inclusions  are 
assimilated  by  the  organism,  they  do  not  diminish  in  volume.  The 
fundamental  difference  between  inclusions  of  inert,  unorganized 
tissues,  such  as  glass  or  gold,  and  dead  organic  tissues,  such  as  bone  or 
cartilage,  lies  in  the  fact  that  the  former  are  foreign  bodies  tolerated 
and  encysted,  whereas  the  latter  are  adopted  and  young  osseous  cells 
are  seen  to  appear  in  them.  The  former  may  be  expelled  one  day, 
whereas  the  latter,  once  admitted,  are  permanent. 

These  inclusions  may  be  made  at  the  same  time  as  the  extirpation, 
but  they  can  also  be  effected  on  extirpations  of  long  standing,  provided 
that  this  extirpation  has  been  properly  made.  It  is  in  this  case 
necessary  to  create  a  pocket  in  the  middle  of  what  remains  of  the 
muscles,  but  the  results  obtained  are  often  excellent  and  comparable 
to  the  best  stumps  consecutive  to  amputation  of  the  anterior  segment. 


368  A.  MAGITOT 

REFERENCES 

Ahlstrom:  Cent.  f.  prat.  Augenh.,  August  17. 

Bartels:  Arch.  f.  Augenh.,  1910. 

Boiadjeff:  These,  Nancy,  1899. 

Bickerton:  Brit.  Med.  Assoc.,  1896. 

Baraquez:  Jahresb.  f.  Opht.,  1901. 

Claiborne:  Brit.  Med.  Jour.,  1887. 

Greenwood:  Arch.  Ophth.,  1914. 

Green:  Ophth.  Rec.,  364. 

Hertel:  v.  Graefe's  Arch.  f.  Ophth.,  1903 

Hepburn:  Jour.  Amer.  Med.  Assoc.,  1902. 

Kuhnt:   Arch.  f.  Augenheilk.,  Ixxi,  and  Korrespondenzblatt  d.  allg.  art.  Verein, 

Tubingen,  1887. 

Lagrange:  Soc.  Med.  et  Chir.  de  Bordeaux,  1900. 
Lang:  Brit.  Med.  Jour.,  1887. 
Lauber:  Zeits.  f.  Augenh.,  1910. 
Mules:  Brit.  Med.  Jour.,  1885. 
Maitland  Ramsay:  Clin.  Ophth.,  1905. 
Marx:  Arch.  f.  Augenh.,  1910. 
Pflueger:   Cong.,  Paris,  1900. 
Posey:  Ophth.  Rec.,  81. 
Sattler:  Heidelberg  Soc.,  1912. 
Schmidt:  Klin.  Mon.  f.  Augenh.,  1896. 
Suker:  Ophth.  Rec.,  1901. 
Tschirkowski :  Arch.  Ophth.,  1912. 
Velez:  Ann.  Ophth.,  1908. 
Verry:  Soc.  Franc..  d'Ophtal.,  1898. 
Walstein:   Klin.  Monats.  f.  Augenh.,  1909. 
Weeks  and  Greenwood,  A.:  Surg.  a.  Gyn.  Soc.,  1920. 
Trousseau:  Ann.  d'Oculistique,  1897. 
de  Schweinitz:  Cong.,  Paris,  1900. 
Swanzy:  Cong.,  Paris,  1900. 
Valude:  Cong.,  Paris,  1900. 

DISCUSSION 

DR.  J.  N.  ROY  (Montreal,  Canada):  J'ai  e"te"  fort  heureux  d'entendre  la 
tres  inte'ressante  communication  de  monsieur  le  Docteur  Magitot  et  d'apres 
ce  qu'il  nous  a  dit,  je  viens  a  la  conclusion  que  les  greffes  adipeuses  et  cartila- 
gineuses  agissent  diffe'remment  en  autant  qir'elles  sont  places  dans  la  cavite" 
oculaire  ou  dans  un  endroit  quelconque  de  la  face  ou  du  crane.  En  effet, 
j'ai  eu  1'occasion  pendant  et  apres  la  guerre  de  pratiquer  un  nombre  consid- 
e"rable  de  greffes  adipeuses,  cartilagineuses  et  osseuses  pour  reparer  des 
lesions  de  la  figure,  des  maxillaires  et  du  crane,  et  c'est  le  re"sultat  de  mon 
experience  personnelle,  compare"  a  ce  que  vient  de  nous  exposer  le  conferencier, 
que  je  desire  vous  soumettre  tres  rapidement. 

D'apres  M.  Magitot,  la  graisse  plac.6e  dans  la  cavite"  oculaire  ne  rendrait 


Orbital  Marsupialization  369 

aucun  service,  puisqu'elle  se  re"sorbe  en  totalitS  dans  un  espace  de  temps 
relativement  court.  Je  serais  curieux  de  savior  si,  apres  1'avoir  experiments, 
il  a  constate  cette  transformation  partielle  du  tissu  adipeux  en  liquide  huileux 
que  Ton  observe  quelquefois,  et  qui  s'Scoule  ensuite  de  1'endroit  ou  le  greffon 
a  StS  plase".  Mise  dans  la  figure  ou  le  cou,  pour  rSparer  esthStiquement  une 
depression  locale,  la  graisse  donne  d'excellents  rSsultats,  .surtout  si  on  a  eu  la 
precaution  d'en  mettre  une  quantity  plus  considerable  que  la  cavite"  a  combler, 
et  apres  I'ope'ration,  d'appliquer  un  bandage  compressif  pour  la  faire  durcir, 
tout  en  diminuant  son  volume  a  volonte".  Ce  greffon  s'adapte  tres  bien  aux 
tissus  environnants  qui  ont  la  meme  consistance  que  lui,  et  si  dans  ce  cas,  il 
se  rSsorbe  tres  peu,  comparativement  a  ce  que  1'on  rencontre  dans  1'oeil  ou 
la  graisse  disparait  totalement,  ce  ph^nomene  est  probablement  du  au  fait 
que  placed  dans  la  cavite"  fibreuse  de  la  coque  oculaire,  cette  graisse,  d'SlSments 
diffSrents  avec  ceux  qui  1'entourent,  perd  sa  vitalite"  et  se  rSsorbe  plus  ou 
moins  rapidement. 

J'ai  eu  aussi  1'occasion  de  me  servir  de  morceaux  d'Sponge  st^rilisSe  pour 
remplir  des  depressions  a  la  figure.  Je  dois  dire  que  dans  tous  les  cas  je 
n'ai  eu  que  des  insucces.  Ce  corps  Stranger,  en  contact  avec  le  tissu  adipeux, 
a  pour  propriete  d'user  les  cellules,  de  les  ramolir,  et  de  les  transformer  en  une 
substance  huileuse  aseptique — controlSe  par  le  microscope, — et  ce  liquide 
s'echappe  a  1'extSrieur  jusqu'a  ce  que  le  morgeau  d'Sponge  soit  a  son  tour 
SlimmSe. 

Monsieur  Magitot  nous  a  dit  que  la  greffe  cartilagineuse  humaine,  plac^e 
dans  la  coque  oculaire,  se  rSsorbe  toujours,  tandis  que  les  zoogreffes — un 
morceau  de  cartilage  de  veau  par  exemple,  garde  pendant  une  dizaine  de 
jours  dans  une  solution  de  formaline — ne  se  resorbe  pas.  Ce  fait  est  encore 
excessivement  intSressant,  puisqu'il  est  reconnu  que  les  greffons  de  cartilage 
animal  employe's  pour  rSparer  une  ISsion  du  crane,  du  sinus  frontal,  de  la 
paroi  orbitaire,  de  1'os  malaire,  du  nez  et  du  maxillaire  infSrieur  se  rSsorbent 
toujours,  tandis  que  les  greffons  pris  sur  un  etre  humain  ne  disparaissent 
jamais,  en  autant  que  1'operation  est  faite  aseptiquement.  D'ailleurs  les 
remarquables  travaux  de  Morestin  sur  ce  sujet  sont  connus  de  vous  tous, 
j'en  suis  sur,  et  ce  tres  habile  chirurgien  greffait  meme  des  morceaux  de 
cartilage  pris  sur  une  autre  personne.  Les  examens  microscopiques  ont 
prouve"  que  la  greffe  animale  sevant  a  rSparer  un  traumatisme  du  crane  ou  de 
la  face,  se  transforme  en  un  tissu  fibreux,  et  qu'elle  se  rSsorbe  ensuite  dans  un 
espace  de  temps  plus  ou  moins  long. 

Aussi  Stant  donne"  la  maniere  tout-a-fait  diffSrente  dont  se  comportent  les 
greffons  de  cartilage  humain  et  animal,  je  suis  portS  a  croire  que  le  fait  de 
garder  pendant  quelques  jours  ces  morceaux  de  zoogreffes  dans  une  solution 
de  formaline,  a  pour  propriStS  de  leur  donner  plus  de  stabilitS,  et  de  les 
empecher  ensuite  de  se  rSsorber;  et  en  terminant,  je  serais  tres  heureux 
de  connaitre  1'opinion  du  confSrencier  sur  cette  hypoth&se. 

DR.  A.  MAGITOT  (closing):  La  question  que  me  pose  le  Dr.  J.  N.  Roy 
concerne  deux  points:  la  greffe  vivante,  la  greffe  morte. 

En  matiere  de  greffe  vivante  il  faut  faire  trois  parts:  Phe'teroplastie  c'est 
a  dire  lorsque  la  greffe  est  pre'levee'  sur  un  individu  d'espece  differente,  Thomo- 
24 


370  A.  MAGITOT 

plastie  lorsquelle  est  prise  sur  un  individu  de  memeespece  et  1'autoplastie  sur 
1'individu  lui  meme. 

Depuis  longtemps  il  est  bien  connu  que  Fhe'teroplastie  vivante  est  de"cevante 
et  je  prie  mon  aimable  interlocuteur  de  bien  vouloir  a  ce  propos  se  reporter  a 
mon  premier  memoire  sur  les  greffes  corne"ennes  qui  a  paru  en  1911  dans 
les  Annales  d'Oculistique. 

En  ce  qui  concerne  1'homoplastie,  ses  chances  de  succes  ont  paru  meilleures. 
En  realite",  les  faits  cliniquesetexperimentaux  sont  assez  nombreux  pour  qu'on 
puisse  juger  de  leur  valeur,  et  je  conseille  au  Dr.  J.  N.  Roy  qui  evoque  le 
souvenir  de  Morestin  de  bien  vouloir  lire  les  discussions  qui  ont  en  lieu  a  la 
Socie"te"  de  Chirurgie  de  Paris  a  propos  des  greffes  osseuses.  De  meme  je  lui 
recommande  la  lecture  des  bulletins  de  la  Socie'te'  de  Biologie  et  les  notes  si 
interessantes  du  Prof.  Nageotte.  De  tout  cela,  il  ressort  que  si  j'avance 
que  les  greffes  vivantes  meurent  au  bout  de  peu  de  temps  et  se  re"sorbent,  ce 
n'est  pas  seulement  une  vue  personnelle,  mais  le  r6sultat  auxquels  sont 
parvenus  d'eminents  experimentateurs.  II  faut  du  reste  bien  remarquer 
que  cette  greffe  qui  ne  survit  pas  est  tres  utile  par  sa  presence  puisqu'elle  sert 
de  trame  a  un  tissu  nouveau.  Le  resultat  cherche"  est  done  souvent  atteint. 

Je  passe  main  tenant  a  la  greffe  de  tissu  adipeux.  De  nombreux  confreres  y 
ont  eu  recours  pour  Porbite.  Les  re"sultats  imme'diats  sout  excellents  les 
re"sultats  e'loigne's  sout  de"testables.  Les  cellules  adipeuses  qui  a  1'etat  vivant 
sont  semi-liquides,  laissent  e"chapper  leur  contenu  huileux  et  ne  sont  pas 
penetre'e  par  un  tissu  nouveau.  La  charpente  est  insuffisante  pour  exciter  la 
production  d'une  masse  conjonctive  jeune  et  Marx  (cite"  par  moi)  a  parfaite- 
ment  mis  cette  question  au  point. 

La  greffe  de  tissu  organique  mort  ne  peut  etre  considere*e  comme  homo-ou 
he"  te"roplastique.  II  s'agit  la  d'une  masse  impersonnelle,  osseuse  ou  cartilagineuse 
qui  par  la  presence  du  tissu  conjonctif  qui  la  recouvre  excite  la  production  de 
cellules  mesodermiques  qui  finissent  par  prendre  le  type  osseux.  Voila 
pourquoi  des  transplantations  de  tissu  fixe  histologiquement  reussissent. 
Peu  importe  que  ce  soit  du  cartilage  ou  de  1'os  de  veau.  C'est  le  tissu  con- 
jonctif qui  importe.  Ou  aurait  sans  doute  un  resultat  comparable  avec  une 
grosse  masse  tendineuse. 

Si  le  Dr.  J.  N.  Roy  vent  bien  essayer  pour  les  reparations  faciales  le  car- 
tilage formole",  ou  fixe  dans  1'alcool,  il  est  probable  qu'il  aura  debonsresultats. 
Je  1'  ai  fait  souvent  pendant  la  guerre  lorsque  je  dirigeais  le  service  ophtal- 
mologique  du  groupe  des  armies  de  1'Est;  je  1'ai  fait  depuis.  Mais  pour 
re"ussir,  il  faut  plus  encore  que  pour  1'orbite,  que  la  plaie  faciale  soit  parfaitement 
aseptique,  et  que  1'on  ait  attendu  pour  intervenir  suffisamment  de  temps 
apres  la  cicatrisation  afin  de  ne  pas  reveiller  un  processusinflammatoire  encore 
recent.  J'ai  ainsi  refait  des  arcades  sourcillieres,  des  pommettes,  des  rebords 
orbitaires  infe"rieurs.  Nul  doute  qu'on  puisse  utiliser  le  meme  materiel 
pour  le  nez. 


LA  PERITOMIA  EN  LAS  ULCERAS  CRONICAS 
VASCULARES  DE  LA  CORNEA 

DR.  ANTONIO  F.  ALONSO 
Mexico,  D.  F. 

En  Tratados  cldsicos  y  Enciclopedias  oftalmologicos  se  habla 
generalmente  solo  de  la  Peritomia  al  tratar  del  panus  de  la  cornea. 
Los  autores  se  refieren  por  lo  comiin  d  esta  intervencion  quirurgica 
al  estudiar  el  tratamiento  de  las  Keratitis  vasculares  consecutivas  d 
las  oftalmias  escrofulosas  6  al  Tracoma.  Las  primeras  producirian 
con  mas  frecuencia  el  panus  superficial  6  panus  tenuis;  el  segundo 
el  panus  crasus  llamado  tambien,  tracomatoso  6  sarcomatoso,  en 
cuya  genesis  toma  parte  con  frecuencia  la  triquiasis  el  entropion  y  el 
ectropion. 

En  el  excelente  tratado  del  Prof,  de  Schweinitz  se  recomienda  en 
la  Keratitis  panosa  tocar  con  el  galvano  cauterio  el  lado  convexo 
del  creciente  vascular  6  hacer  una  libre  peritomfa. 

En  la  ultima  edicion  inglesa  de  la  obra  del  Prof.  Fuchs  el  Prof. 
Duane  traductor,  hace  la  anotacion  interesante  que  la  peritomfa  se 
prdctica  para  curar  un  grueso  panus  y  algunas  veces  en  otras  con- 
diciones  como  la  episcleritis,  herpes,  acne  rosacea. 

Verhoeff — dice  Darier  en  sus  Tratados  de  Terapeutica  ocular — que 
considerando  la  acnea  corneal  de  naturaleza  neuro-trofica,  prdctica 
en  esta  enfermedad  una  peritomia  despegando  la  conjutiva  y  cu- 
briendo  con  ella  las  lesiones  corneales. 

En  la  Enciclopedia  Francesa  de  Oftalmologfa  el  Dr.  Valude  habla 
solamente  de  la  Peritomia  al  referirse  al  panus  corneal. 

En  el  bello  libro  de  cirujia  del  Dr.  Terson  se  afirma  que  la  peritomfa 
es  un  medio  precioso  en  muchos  casos  para  los  panus  de  toda  na- 
turaleza y  para  las  manchas  vascularizadas  de  la  cornea.  Se  agrega : 
"aciertas  ulceras  pueden  tambien  beneficiar." 

En  el  reciente  tratado  de  cirujia  ocular  del  Dr.  Terien,  asi  como  en 
la  obra  tan  completa  de  oftalmologfa  del  Prof.  Axenfeld,  no  se  habla 
de  la  peritomia  sino  para  combatir  el  panus  tracomatoso. 

Como  se  v4  por  lo  anteriormente  expuesto,  para  no  citar  sino 

371 


372  ANTONIO  F.  ALONSO 

algunas  solamente  de  las  obras  mds  importantes,  no  se  ha  hecho  un 
estudio  metodico,  especial,  te'cnico,  de  las  indicaciones  de  la  peritomia 
en  las  lilceras  cronicas  vasculares  de  la  cornea,  cual  creemos  nosotros, 
lo  merecerfa  por  su  importancia. 

Nuestra  diaria  experiencia  nos  ha  ensenado  todo  lo  frecuente  que 
es  encontrar  enfermos  portadores  no  de  panus  crasus  6  tenuis;  no 
de  esas  corneas  enrojecidas  y  carnosas  consecutivas  d  la  oftalmia 
tracomatosa  6  escrofulosa,  en  que  el  diagn6stico  se  impone  con  la 
necesidad  de  una  evidencia  ffsica;  ni  siquiera  se  trata  de  un  pequeno 
grupo  de  ulceras  localizadas  en  algiin  sector  corneal  vascularizadas 
mds  6  menos  intensamente,  no.  Se  trata  de  una,  dos,  6  tres  ulceras 
pequenas,  de  origen  variable,  trasparentes,  u  opacas,  solas  6  acorn- 
panadas  de  algunas  manchas  cicatrizales;  ulceras  que  son  el  punto  de 
terminaci6n  de  algunos  vasos,  bien  visibles  muchas  veces  s61o  con  la 
ayuda  de  la  lente,  insignificante  al  parecer,  cronicas  y  rebeldes  d 
todos,  los  tratamientos  habituales.  Muchos  de  estos  pacientes  han 
recorrido  clinicas  y  gabinetes  oftalmologicos  donde  han  sido  tratados 
durante  muchos  meses  por  toda  la  gama  de  excitantes:  calomel 
oxide  amarillo  de  Hg,  dionina,  fomentos  calientes,  masajes  electricos, 
etc.,  etc.,  sin  obtener  mejorfa  alguna.  Una  peritomfa  ignea  ha 
terminado  en  8  6  15  dfas  en  una  completa  curacion  de  los  pacientes. 
Estas  ulceras  no  producen  generalmente  grandes  molestias;  algo 
de  lacrimoso,  algunos  pequenos  dolores,  y  son  casi  compatibles  con  la 
vida  ordinaria.  Los  enfermos,  sobre  todo  cuando  las  ulceras  estdri 
acompanadas  de  opacidades  de  la  cornea,  preocupados  ma's  que  por 
otra  causa  por  la  disminucion  de  la  agudeza  visual,  consultan  fre- 
cuentemente  en  este  sentido  al  oculista.  No  siempre  estas  ulceras 
son  resultado  de  oftalmias  tracematosas  6  impetiginosas,  se  observan 
como  consecuencias  de  herpes  corneales,  keratitis  tuberculosas,  como 
el  caso  que  relatamos  despue"s. 

iCual  deberd  ser  en  estos  casos  el  criterio  del  oftalmologo?  Es 
principie  de  Patologia  Oral,  que  los  vasos  son  los  principales  encar- 
gados  de  llevar  los  materiales  de  reparacion  a  los  tejidos,  y  parecerfa 
paradojico  interrumpir  los  elementos  vasculares  para  la  cicatrisation 
de  una  ulcera  corneal.  Que  elementos  informardn  entonces  el  juicio 
del  especialista  para  saber  el  momento  en  que  los  vasos,  en  lugar  de 
conducir  elementos  litiles  d  la  reparacion  de  una  ulcera  en  la  cornea, 
llevan  las  celdillas  emigratrices  de  la  opacificacion  y  de  la  esclerosis, 
que  profundizando  la  membrana  de  Bowman  hardn  indeleble  la 
Iesi6n,  como  lo  han  demostrado  los  bellos  estudios  de  Iwanoff? 


La  Peritomia  en  las  Ulceras  Cronicas  Vasculares  de  la  Cornea     373 

Varies  elementos  deberdn  d  nuestro  juicio  ilustrar  el  criterio  clinico 
del  oftalmologista.  Desde  luego  la  antiguedad  de  la  lesion.  Ulceras 
cronicas  rebeldes  d  todo  tratamiento,  deberian  hacer  pensar  iempre 
en  la  posibilidad  de  ulceras  mantenidas  por  vasos  anormales  de  la 
cornea.  Nunca  el  oculista  deberd  despreciar  en  estos  casos  examinar 
d  la  lente  de  una  manera  cuidadosa  la  membrana  trasparente.  El 
factor  causal  se  presenta  bajo  la  forma  de  vasos  superficiales,  tortuosos, 
varicosos,  poco  sensibles  &  la  accion  de  la  adrenalina.  Son  estas 
lilceras  corneales  a  las  que  se  refiere  Darier  sin  duda  en  su  Tratado  de 
Terapeutica,  con  el  caracter  de  no  tenirse  con  la  florescina. 

El  tratamiento  en  estos  casos  por  medio  de  todos  los  excitantes  y 
aun  el  recubrimiento  conjuntival,  es  intitil.  La  peritomia  es  la 
terapeutica  heroica  que  salvard  ojos  destinados,  de  otra  suerte,  d 
la  perdida  de  la  vision  por  opacidad  y  esclerosis  corneal. 

La  peritomia  es  una  de  las  operaciones  mds  antiguas  de  la  oftal- 
mologia.  Aunque  se  atribuye  a  Furnari  como  el  inventor  a  mediados 
del  pasado  siglo,  es  mucho  ma's  antigua,  pues  segiin  Terson  se  en- 
cuentra  ya  en  Guy  de  Chauliac,  quien  la  tomo  de  los  drabes. 

La  operacion  estd  constituida  por  la  desinsercion  conjuntival  al 
derredor  de  la  cornea.  Si  en  lugar  de  una  simple  incision  se  reseca 
una  lengueta  de  tejido  conjuntival,  se  llama  periectomia  6  sindec- 
tomia. 

Algunos  autores  como  Panas  conceptuan  suficiente  la  simple 
peritomia  y  dividen  los  vasos  muchas  veces  por  medio  de  la  punta 
fina  del  termo  6  galvano-cauterio,  lo  que  se  ha  llamado  la  peritomia 
ignea. 

Nuestra  experiencia  nos  ha  ensenado  que  la  peritomia  ignea  no 
s61o  tiene  ventajas  por  la  rapidez  de  su  ejecucion,  sino  que  nos  parece 
de  especial  efecto,  para  evitar  reincidencias,  debido  a  la  esclerosis 
consecutiva  d  la  cauterisation. 

Esta  intervention  quirurgica  no  solo  produce  excelentes  resultados 
para  la  cicatrisacion  de  las  ulceras  cronicas  vasculares  de  la  cornea, 
sino  la  mejoria  de  la  opacidades  que  los  acompafian,  imposible  de 
obtener  con  las  inyecciones  subconjuti vales  y  dema's  medios  tera- 
p^uticos  conocidos. 

Siendo  prolija  la  descripcion  de  los  multiples  casos  que  en  rela- 
cion  con  este  estudio  hemos  observado  en  nuestra  prdctica,  y  fuera 
del  proposito  de  estas  lineas,  recordaremos  muy  brevemente  los  tres 
ultimos,  de  grande  interes  clinico. 


374  ANTONIO  F.  ALONSO 

Obs.  1 

H.  M.  Mujer  de  30  anos  escrofulosa.  Padece  desde  su  infancia 
de  los  ojos.  El  ojo  isquierdo  tiene  una  serie  de  pequenas  manchas 
cicatrizales  en  la  cornea,  huellas  de  antiguas  erupciones  flictenulares, 
obstruyendo  en  parte  la  pupila  y  habiendo  producido  un  estigmatismo 
iregular  que  compromete  algun  tanto  la  vision.  OIV  =1/3.  El 
ojo  derecho  tiene  varias  manchas  que  obstruyen  completamente  la 
pupila,  dejando  libre  un  sector  infero  interne  de  la  cornea,  y  2  ulcera- 
ci6nes  centrales  d  donde  van  d  terminar  algunos  vasos  delgados, 
tortuosos,  poco  visibles,  viniendo  de  la  de  parte  superior  del  globo. 

La  agudeza  visual  de  la  enferma  se  reducia  d  contar  los  dedos  d 
2  metres  de  distancia,  teniendo  este  ojo  lacrimoso  y  adolorido.  Ten- 
sion normal. 

Cuando  1  vimos  a  esta  enferma  tenfa  9  meses  de  tratamiento  casi 
continue  con  oculistas  en  varias  partes  de  la  Republica,  bajo  la  accion 
de  la  pomada  amarilla  de  hg.,  calomel,  dionina,  atropina,  inyecciones 
subconjunti vales,  tonicos,  yodurados,  inyecciones  intramusculares  de 
hg.,  etc.,  sin  obtener  alivio  alguno. 

El  10  de  Enero  de  1920  practicamos  una  peritomia  ignea  superior 
con  el  galvano-cauterio  fino,  haciendo  la  seccion  profunda  de  los  vasos 
corneales.  Oclusion  del  ojo  que  se  cura  diariamente.  A  los  15  dlas 
no  solo  estaban  las  ulceras  cicatrizadas,  sino  las  manchas  acom- 
panantes  se  redujeron  y  esclarecieron  notablemente.  Una  iridectomia 
infero-interna  practicada  d  la  enferma  despues,  le  hizo  ascender  su 
agudeza  visual  d  1/3. 

Obs.  2 

V.  T.  Nino  de  12  anos  de  edad  linfdtico,  ha  padecido  desde  hace 
varies  anos  ataques  de  Kerato  conjuntivitis  impetiginosa  en  ambos 
ojos.  El  tiltimo,  que  data  de  siete  meses,  ha  dejado  un  pequeno 
grupo  de  ulceraciones  en  el  sector  infero  interne  de  la  cornea,  vascu- 
larizadas  y  rebeldes  d  todo  tratamiento.  Consulta  con  varios  espe- 
cialistas  de  la  frontera  norte  de  Mexico  y  de  San  Antonio,  Texas,  que 
lo  tratan  per  medio  de  tonicos,  fiero,  arsenicales,  y  localmente  con 
fomentaciones  calientes,  pomada  amarilla,  dionina,  etc.,  sin  resultado. 

El  10  de  Mayo  de  1920  le  practicamos  una  peritomia  en  todo  la 
parte  inferior  6  interna  del  globo,  con  infiltracion  conjiintival  a  la 
novocaina  adrenalina.  El  resultado  fu6  verdaderamente  sorprendente, 
pues  d  los  10  dias  se  encontraban  las  ulceras  absolutamente  cicatrizadas 
sin  haber  dejado  opacificacion  alguna. 


La  Peritomia  en  las  Ulceras  Cronicas  Vasculares  de  la  Cornea      375 

Obs.  3 

M.  C.  Senora  de  50  afios  de  edad.  El  afio  de  1918  le  atendimos 
un  lupus  de  la  nariz  que  habia  invadido  la  conjuntiva  y  borde  corneal 
del  ojo  izquierdo.  Le  tratamos  por  inyecciones  de  tuberculina  con 
excelentes  resultados  habiendo  desaparecido  por  complete  la  lesion. 
Vuelve  a  enfermarse  su  ojo  izquierdo  d  principios  de  1920  poniendose 
el  organo  rojo,  doloroso  y  disminuyendo  notablemente  la  vision. 
Consulta  con  varios  oculistas  de  la  capital,  ausente  nosotros  de  ella, 
d  la  sazon,  que  le  tratan  por  medio  de  fomentos  calientes,  dionina, 
argirol  pomadas  varias,  masaje  electrico,  etc.,  sin  resultado  favorable. 
Volvemos  aver  la  enferma  en  Agosto  de  1921,  ynos  encontramos  una 
ulcera  central  de  la  cornea  de  forma  redonda  y  de  2  mils  de  ex  ension, 
invadida  por  dos  6  tres  vasos  delgados,  tortuosos,  desprendidos 
de  la  parte  superior  del  globo  y  acompanada  por  una  corona  de  man- 
chas  cicatrizados  que  ocupaban  gran  parte  de  la  cornea.  La  ulcera 
no  se  teiiia  por  la  florescina.  El  ojo  lacrimoso,  sensible  d  la  luz  y 
doloroso,  y  con  la  vision  perdida.  La  tension  del  organo  era  normal. 
No  se  habia  reproducido  el  antijuo  lupus  nasal. 

Ante  la  rebeldia  de  1  afio  y  medio  d  todos  los  tratamientos  de 
aquella  lesion  ocular,  practicamos  a  la  enforma  desde  luego  el  15  de 
agosto  de  1921  una  peritomia  ignea  superior  dividiendo  d  la  lente 
binocular  todos  los  vasos  que  penetraban  en  la  cornea.  Desde  el 
tercer  dia  se  comenzo  d  ver  una  mejorfa  notable  en  el  estado  local  de  la 
enferma  y  d  los  20  dfas  se  encontraba  la  ulcera  absolutamente  ci- 
catrizada.  Las  manchas  corneales  se  ban  esclarecida  de  tal  modo 
despues  de  la  intervencion,  que  la  paciente  ha  alcanzado  una  agudeza 
visual  de  1/10  y  rehusado  a  una  iridectomia  optica  que  le  habfamos 
propuesto. 

Esta  breve  comunicacion  podrfamos  sintetizarla  en  algunas  con- 
clusiones.  la.  El  unico  tratamiento  eficiente,  y  con  frecuencia  her6ico, 
de  las  ulceras  cronicas  y  vascularizadas  de  la  cornea  es  la  Peritomia. 
2a.  En  toda  ulcera  corneal  cronica  rebelde  a  los  tratamientos  varios 
usuales,  el  oculista  debera  sistematicamente  examinar  la  cornea  d  la 
lente,  para  definir  si  no  existen  vasos  mantenedores  de  la  lesion.  3a. 
La  frecuencia  de  estas  ulceraciones,  su  rebeldia  a  la  Terapeutica 
ordinariamente,  empleada,  y  las  consecuencias  funestas  que  tienen 
para  la  funcion  visual,  meritan  que  los  tratadistas  los  consagren  una 
atencion  mds  amplia  y  un  sitio  mds  importante  en  la  nosografia, 
oftalmologica. 


376  ANTONIO  F.  ALONSO 

DISCUSSION 

DR.  L.  WEBSTER  Fox  (Philadelphia):  Considerable  credit  is  to  be  given 
to  this  author  for  bringing  to  the  attention  of  the  ophthalmic  world  the  value 
of  this  therapeutic  measure.  Many  times  in  the  past  have  prominent  surgeons 
noted  the  value  of  this  operation  but  have  failed  to  impress  it  sufficiently 
upon  their  students  and  followers,  so  that  it  has  just  so  often  been  allowed 
to  fall  into  the  discard,  to  be  revived  from  time  to  time  by  some  progressive 
surgeon  who  has  had  to  discover  for  himself  the  great  benefit  to  be  derived 
from  its  employment. 

Dr.  Alonso  adds  a  note  to  the  indications  for  its  use  when  he  advises  the 
operation  in  chronic  vascular  ulcers  of  the  cornea.  His  comment  that  it  has 
been  referred  to  mostly  in  connection  with  pannus  secondary  to  scrofulous 
and  trachomatous  inflammation  is  accurate,  and  it  is  rather  unfortunate  that 
the  authorities  he  quotes  should  be  averse  to  admitting  of  its  larger  possi- 
bilities, and  indeed  rather  reluctant  to  acknowledge  even  its  usefulness  in 
that  obstinate  condition,  pannus.  The  French  have  given  it  a  much  higher 
status  than  the  Americans,  as  Dr.  Alonso  has  shown.  His  personal  experi- 
ence with  intractable  ulcers  is  of  great  interest  and  shows  close  attention  to 
minute  clinical  detail.  It  is  most  certainly  necessary,  as  he  implies,  to  bring 
about  resolution  in  these  cases  in  order  to  avoid  the  scarring  of  the  cornea  and 
the  consequent  disturbance  of  vision. 

Ifc-is  agreeable  to  note  that  Dr.  Alonso  stresses  the  importance  of  good 
ophthalmic  judgment  in  deciding  when  the  vessels  leading  to  one  of  these 
ulcers  has  ceased  to  conduct  useful  elements  for  the  reparation  of  the  ulcer 
ated  site,  and  instead  carry  migratory  cells  of  opacification  and  sclerosis  He 
regards  with  good  cause  the  age  of  the  ulcer  as  an  index  of  its  patholog  c 
condition.  The  chronic  rebellious  ulcer  is  maintained  by  normal  blood- 
vessels. It  is  in  this  phrase  of  Dr.  Alonso's  that  the  whole  story  of  rebellious 
ulcers  is  told.  The  vessels  are  abnormal.  At  no  time  are  blood-vessels 
normal  to  the  cornea,  and  these  fine  red  lines  which  we  see  in  these  cases, 
while  .they  carry  blood  are  not  blood-vessels  in  the  histologic  sense  but  are 
the'  same  capillary  loops  that  we  see  in  all  forms  of  exuberant  granulation. 
These  ulcers  are  in  fact  exuberant  granulations.  In  any  other  situation  the 
surgeon  would  entertain  no  other  treatment  than  complete  eradication.  Dr. 
Alonso  prefers  what  he  terms  "igneous  peritomy,"  which  consists  of  division 
of  the  vessels  many  times  by  means  of  the  fine  point  of  the  galvano-cautery. 
The  scarring  produced  by  this  cauterization  is  believed  to  prevent  recur- 
rences. 

There  must  be  a  great  merit  to  this  method  as  his  experience  coincides 
with  my  own.  My  own  preference  has  been  for  a  clean  excision  of  the  con- 
junctiva surrounding  the  cornea,  and  an  experience  of  over  a  thousand  cases 
in  the  last  twenty  years  since  I  first  used  this  method  convinces  me  that  my 
selection  of  this  technic  is  the  correct  one.  The  operation  is  a  modification  of 
that  of  Furnari  and  is  known  in  many  circles  as  "peridectomy." 

The  tachnic  consists  first  of  anesthetization  of  the  conjunctiva  with  a  five 
per  cent,  solution  of  cocain,  and  the  additional  installation  of  a  drop  or  two 
of  adrenalin  solution  to  control  slight  hemorrhage.  A  strip  of  bulbar 


La  Peritomia  en  las  Ulceras  Cronicas  Vasculares  de  la  Cornea  377 

conjunctiva  from  5  mm.  to  15  mm.  immediately  surrounding  the  cornea  is 
then  excised  with  sharp  scissors.  The  vessels  on  the  cornea  at  the  limbus  are 
then  scarified  by  means  of  a  sharp  curved  knife  devised  by  myself  but  no 
cauterant  is  used.  Special  emphasis  must  be  laid  upon  the  necessity  of  a 
clean  cut  incision  of  the  conjunctiva.  Chewing  of  the  conjunctiva  with  dull 
or  imperfectly  set  scissors  will  induce  an  unnecessary  inflammation. 

When  Furnari  brought  forth  his  operation  in  1842,  trachoma  was  present 
in  a  most  virulent  type  in  the  French  Army  and  in  the  French  Colonial 
possessions,  and  his  enormous  experience  with  this  disease  in  Algiers  prompted 
him  to  the  development  of  a  radical  technic  in  the  expectation  of  checking  the 
ravages  of  the  disease.  His  operation  consisted  in  first  making  an  incision  at 
the  outer  canthus,  after  which  a  broad  ring  of  bulbar  conjunctiva  was  excised 
extending  from  the  margin  of  the  cornea  to  within  3  mm.  of  the  line  where  the 
conjunctiva  is  reflected  from  the  globe  to  the  inner  surface  of  the  lid.  A  flap 
of  conjunctiva  at  the  margin  of  the  cornea  was  allowed  to  remain  to  the  last 
in  order  to  fix  and  rotate  the  globe  at  the  will  of  the  surgeon  during  the  opera- 
tion. The  conjunctival  tissue  was  then  carefully  dissected  away  so  as  to 
expose  the  sclera  to  view.  The  vessels  of  the  cornea  were  then  scarified, 
after  which  the  sclera  and  ulcerated  portions  of  the  cornea  were  touched  with 
silver  nitrate. 

The  success  attending  Furnari's  cases  led  other  surgeons  to  practise  this 
operation  but  with  innumerable  modifications.  One  of  the  early  and  prob- 
ably the  best,  was  to  discard  the  cauterizing  feature.  This  is  mentioned  here 
in  order  to  call  attention  to  the  fact  that  attractive  as  the  cauterizing  may 
appear,  it  has  always  been  discarded  after  any  prolonged  experience  with  it. 
However,  it  may  be  that  the  use  of  the  galvano-cautery  may  be  a  little  more 
elegant  and  give  a  much  better  result  than  the  cauteries  used  in  bygone  days. 
In  closing  the  discussion  I  wish  to  call  the  author's  attention  to  my  article  in 
the  American  Annals  of  Ophthalmology,  October,  1903. 

DR.  S.  LEWIS  ZIEGLER  (Philadelphia):  I  want  to  endorse  what  Dr.  Fox 
has  said  in  regard  to  the  advantages  of  peridectomy  over  peritomy,  or  peri- 
dotomy  as  it  should  be  designated.  The  operation  of  Furnari  is  successful 
in  cutting  off  the  vascular  supply  in  these  cases.  I  recall,  however,  that  in 
addition  to  this  Dr.  Fox,  about  thirty-five  years  ago,  used  Burow's  operation 
to  release  the  tension  of  the  lid. 

The  two  points  in  these  cases  of  vascular  ulcer  are — (1)  the  maceration  and 
(2)  the  lid  tension.  I  have  used  galvano-cautery  peridectomy  extensively, 
but  after  1890  I  abandoned  it,  for  the  reason  that  I  found  I  could  gain  the 
same  result  without  conjunctival  destruction  by  resorting  to  rapid  dilatation 
of  the  tear  duct  to  relieve  the  maceration  and  cantholysis  to  release  the  lid 
tension.  There  is  destruction,  as  a  rule,  in  peridectomy,  because  if  you  take 
off  a  strip  of  conjunctiva  when  it  is  already  atrophic  you  shorten  it  and  cause 
xerosis.  By  stretching  the  tear  duct  you  relieve  the  corneal  maceration  and 
by  the  operation  of  cantholysis  you  release  the  tension  of  the  lid,  and  thereby 
gain  freedom  from  friction  of  the  cornea.  I  advocated  these  measures  in  a 
paper  on  "The  Surgery  of  Trachoma,"  presented  before  the  American  Medical 
Association  in  1898. 


378  ROBERT  CARTWRIGHT  CHENEY 

There  is  only  one  thing  that  must  be  observed  in  this  operation.  Canthot- 
omy  or  cantholysis,  as  Agnew  preferred  to  call  it,  means  the  division  of  the 
external  (superior)  canthal  ligament.  In  performing  the  operation  you  make 
a  small  incision  at  the  external  canthus  with  sharp-pointed  scissors,  then  with 
forceps  you  grasp  the  border  of  the  superior  lid  at  the  point  of  incision,  pass 
in  your  scissors  and  feel  for  the  canthal  ligament  just  as  you  would  feel  for 
the  optic  nerve  when  you  enucleate.  As  soon  as  you  feel  the  ligament,  open 
your  scissors  and  divide  it,  and  the  corner  of  the  lid  will  jump  up  about  a 
centimeter.  If  you  do  not  get  that  freedom  of  the  upper  lid  you  have  not 
divided  the  ligament. 

DR.  ALONSO  (closing) :  To  estimo  en  alto  grado  que  los  Senores  profesores 
que  han  hecho  uso  de  la  palabra  £  prop6sito  de  mi  trabajo  esten  en  el  fondo 
de  acuerdo  commigo;  muy  especialmente  celebro  y  estimo  las  f rases  del  Dr. 
Fox,  que  le  ha  merecido  elogias  mi  actuaci6n  en  esta  asamblea  al  traer  d  su 
seno  la  question  del  tratamiento  de  las  ulceras  cr6nicas  y  vasculariza  das 
de  la  cornea. 

El  asunto  esencial  es  que  no  hay  que  con  fundio  el  tratamiento  quirurgico 
del  Panus  corneal  en  el  cual  la  peritomia  esta  recommendada  fur  les  autores 
con  las  tridicaciones  de  esta  operacion  en  las  ulceraciones  que  hacen  el  objeto 
de  un  comunicacion. 

Como  lo  indico  ampliamente  en  mi  trabajo  estas  ulceraciones  son  muchas 
veces  discretas  y  mantenidas  por  vasos  quisibles  solamente  con  ayuda  de  la 
lente.  Todes  los  tratamientos  excitantes  conocidos  como  la  dioni  na  las 
fomentaciones  calientes  el  exido  amarillo  de  hyla  canterisaciones  la  electrici- 
dad,  el  recubrimiento  conjuntival  mismo,  no  producen  resultado.  Nelo 
con  la  peritomia  se  obtienen  resultados  excelentes  y  definitives,  ha  gran 
cuestion  es  hacer  el  diagnostico  ele  sus  indicaciones  acerca  de  las  cuales  insisto 
ampliamente  en  mi  trabajo.  Ulceraciones  cronicas  vascularizadas,  rebeldes  a 
les  tratamientos  ordinarios,  no  colorandose  por  la  florescina,  etc. 


TYPES  OF  PNEUMOCOCCUS  FOUND  IN 
CORNEAL  ULCERS 

ROBERT  CARTWRIGHT  CHENEY,  M.D. 

Boston,  Mass. 
(From  the  Massachusetts  Charitable  Eye  and  Ear  Infirmary) 

In  1902  Romer,1  realizing  the  inadequacy  of  the  treatment  of 
pneumococcus  ulcer  of  the  cornea  and  the  disastrous  end  result  as  far 
as  useful  vision  was  concerned,  attempted  serum  treatment  in  these 
cases.  Using  small  doses  of  immunized  animal  serum,  he  had  promis- 
ing results  in  rabbits.  In  men,  however,  the  results  were  by  no  means 

1  Romer,  P.:  Experimentelle  Grundlagen  fur  klinische  Versuche  einer  Serum- 
therapie  des  Ulcus  cornea  serpens  nach  Untersuchungen  liber  Pneumokokkenim- 
munitat,  Arch.  Ophth.,  1902,  liv,  99. 


Types  of  Pneumococcus  Found  in  Corneal  Ulcers  379 

as  striking,  and  in  the  five  cases  treated  only  three  were  apparently 
successful.  A  significant  fact  is  that  these  three  cases  were  only 
forty -three,  thirty-one,  and  sixteen  years  of  age,  and  hence  had  a  much 
better  chance  of  recovery  under  any  treatment.  Indeed  the  serum 
treatment  has  never  proved  of  any  clinical  value  and  has  never  sur- 
planted  cauterization  or  other  previously  recognized  forms  of  therapy. 

In  recent  years  the  value  of  serum  treatment  in  cases  of  lobar 
pneumonia  has  apparently  been  proved  and  a  very  satisfactory  sum- 
mary is  given  in  a  monograph  from  the  Rockefeller  Institute  by 
Avery,  Chickering,  Cole,  and  Dochez.1  It  was  found  that  pneumococci 
might  be  divided  into  four  types  on  the  basis  of  their  specific  immunity 
reactions.  To  quote  directly,  "pneumococci  of  types  of  I,  II,  and  III, 
which  compose  about  80  per  cent,  of  all  strains  encountered  in  disease, 
and  which  represent  three  apparently  fixed  types  of  highly  parasitic 
organisms,  each  possessing  common  immunologic  characters."  Type 
III  is  the  pneumococcus  mucosus.  Type  IV  pneumococcus  is  a  hetero- 
geneous group  and  is  mostly  made  up  of  individual  strains  which  are 
not  interrelated  and  do  not  have  a  common  agglutination  reaction 
with  any  single  immune  serum.  In  short,  it  is  possible  to  obtain  three 
stock  sera,  types  I,  II,  and  III,  which  have  specific  agglutination  reac- 
tions for  the  corresponding  types  of  pneumococci,  but  as  is  evident 
from  the  preceding  statement,  there  is  no  type  IV  serum,  and  a 
pneumococcus  which  does  not  agglutinate  any  of  the  three  sera  is 
relegated  to  the  type  IV  group.  In  the  actual  clinical  application  of 
these  sera,  the  type  I  serum  in  large  intravenous  doses  is  seemingly 
highly  effective  in  lobar  pneumonia  caused  by  a  type  I  organism,  but 
of  no  use  in  a  case  caused  by  a  pneumococcus  of  another  type.  Type 
II  and  III  sera  as  yet  have  not  been  proved  to  be  of  clinical  value. 

In  view  of  the  above  facts  it  seemed  important  to  ascertain  the 
types  of  pneumococcus  found  in  corneal  ulcers,  with  the  hope  of  find- 
ing an  ulcer  caused  by  a  type  I  organism  which  might  advantageously 
be  treated  with  serum. 

Some  difficulty  was  encountered  at  first  in  obtaining  a  satisfactory 
culture  medium  as  naturally  comparatively  little  material  for  inocula- 
tion is  obtainable  from  a  corneal  ulcer.  Intraperitoneal  injection  in 
white  mice  was  not  satisfactory,  but  Avery  medium  proved  to  be  just 
what  was  needed,  and  I  never  failed  to  get  a  growth  from  a  pneumo- 

1  Monograph  of  The  Rockefeller  Institute  for  Medical  Research.  No.  7.  Acute 
Lobar  Pneumonia,  Prevention  and  Serum  Treatment,  by  Oswald  T.  Avery,  M.D., 
H.  T.  Chickering,  M.D.,  Rufus  Cole,  M.D.,  and  A.  R.  Dochez,  M.D. 


380  ROBERT  CARTWRIGHT  CHENEY 

coccus  ulcer  when  this  medium  was  employed.  It  was  described  by 
Avery  in  1918 l  and  is  a  meat  infusion  broth  three-tenths  to  five- 
tenths  acid  to  phenolphthalein.  To  each  100  c.c.  of  broth  is  added  5  c.c. 
of  20  per  cent,  sterile  glucose  solution  and  5  c.c.  sterile  defibrinated 
blood. 

The  following  was  the  method  of  procedure :  the  eye  was  carefully 
cocainized,  a  speculum  inserted,  and  as  much  material  as  possible  ob- 
tained by  curetting  the  advancing  infiltrated  edge  of  the  ulcer,  which 
was  found  to  be  the  only  place  where  pneumococci  were  plentiful 
enough  to  give  a  satisfactory  culture.  Great  care  should  be  taken 
not  to  traumatize  the  normal  corneal  tissue,  and  the  ulcer  should  be 
cauterized  immediately  after  curetting,  as  curetting  alone  tends  to 
make  the  process  somewhat  worse.  Next,  a  tube  of  Avery  medium  was 
inoculated  with  the  material  so  obtained  and,  after  careful  shaking, 
was  placed  in  the  incubator  for  six  to  ten  hours  at  the  end  of  which 
time  the  blood  corpuscles  had  settled  at  the  bottom  of  the  test  tube. 
The  supernatant  fluid  was  almost  always  found  to  contain  a  pure 
growth  of  pneumococci  and  from  this  the  type  was  ascertained  by 
direct  microscopic  agglutination  with  the  sera  obtained  from  the  New 
York  State  Board  of  Health  and  the  solubility  of  the  organisms  in  bile 
determined  (pneumococci  soluble  in  bile,  streptococci  not).  Romer 
called  attention  to  the  usual  occurrence  of  a  pure  growth  in  pneumococ- 
cus  ulcer  of  the  cornea,  obtaining  18  pure  cultures  in  20  cases.  Thus  no 
centrifuging  was  necessary,  and  the  culture  was  directly  grouped,  the 
reaction  being  a  combination  of  agglutination  and  precipitation.  Care 
should  be  taken,  however,  not  to  allow  cultures  to  go  over  10  to  12 
hours  as  the  organisms  in  Avery  medium  form  acid  which  soon  kills 
them.  * 

During  a  period  of  over  a  year  at  the  Massachusetts  Charitable 
Eye  and  Ear  Infirmary  cultures  were  obtained  from  12  cases  of 
pneumococcus  ulcer  of  the  cornea.  These  were  pure  cultures  with  but 
one  exception,  where  there  was  a  slight  growth  of  staphylococcus. 
In  eight  of  these  cases  the  organism  was  type  IV  pneumococcus, 
while  in  the  other  four  cases  it  was  type  III  pneumococcus.  No  type 
I  or  type  II  organisms  were  found,  the  percentage  being  66.6  per  cent, 
type  IV,  and  33.3  per  cent,  type  III.  From  the  standpoint  of  any 
serum  treatment  the  results  were  very  disappointing,  but  nevertheless 

1  Avery,  O.  T. :  Determination  of  Types  of  Pneumococcus  in  Lobar  Pneumonia. 
A  Rapid  Cultural  Method.  Jour.  Amer.  Med.  Assn.,  January,  1918,  Ixx,  17. 


Types  of  Pneumococcus  Found  in  Corneal  Ulcers  381 

interesting  when  compared  with  the  following  statistics  taken  from 
Monograph  7  of  the  Rockefeller  Institute: 

1.  Occurrence  of  the  various  types  of  pneumococci  in  lobar  pneu- 
monia and  the  mortality. 

Occurrence  Mortality 

Type     1 33.3%  Type     1 25% 

Type    II 29.3%  Type    II 32% 

Type    II  (Atypical) 4.2%  Type  III 45% 

Type  III 13.0%  Type  IV 16% 

Type  IV :..  20.3% 

2.  Types  of  pneumococci  found  in  mouths  of  normal  persons  (297) . 
Present  116  cases.    Absent  181. 

Type     I 0.9% 

Type    II 0.0% 

Type    II  (A)  0.8% 

Type    II  (B)  5.8% 

Type    II  (X) 11.6% 

Type  III 28.1% 

Type  IV 52.9% 

3.  Types  of  pneumococcus  recovered  from  dust  in  rooms  in  which 
lobar  pneumonia  had  not  occurred. 

Type     I • 5.5% 

Type    II 0.0% 

Type    II  (A)  0.0% 

Type    II  (B)  22.0% 

Type    II  (X)  16.6% 

Type  III 11.0% 

Type  IV 44.4% 

The  preceding  statistics  show  that  of  the  types  of  pneumococci 
found  in  the  mouths  of  normal  people  28.1  per  cent,  are  type  III  and 
52.9  per  cent,  are  type  IV  which  compare  fairly  closely  with  33.3  per 
cent,  and  66.6  per  cent,  respectively  as  found  in  corneal  ulcers.  Thus 
it  is  to  be  wondered  if  the  conjunctiva  or  the  tear  sac  in  clinically  nor- 
mal persons  does  not  also  contain  type  III  and  IV  organisms  as  well 
as  the  mouth. 

Of  the  12  corneal  ulcers  studied  by  me  11  were  clinically  typical 
serpent  ulcers,  but  one  case  needs  special  description :  a  boy  13  years 
old  with  a  severe  membranous  conjunctivitis  and  a  very  superficial 
corneal  ulceration  which  was  secondary  to  the  conjunctivitis.  Type 
III  pneumococcus  was  isolated  from  the  conjunctiva.  This  eye  re- 
covered quickly  with  no  impairment  of  vision. 

In  lobar  pneumonia,  type  III  pneumococcus  is  by  far  the  most 
virulent,  carrying  a  45  per  cent,  mortality,  so  naturally  there  arises  the 
question  of  prognosis  in  eye  infections  as  determined  by  the  type  of 


382  ROBERT  CARTWRIGHT  CHENEY 

pneumococcus.  In  this  extremely  small  series  with  various  methods  of 
treatment,  etc.,  no  definite  evidence  is  obtainable,  but  it  does  seem 
significant  that,  in  the  11  cases  of  ulcus  serpens,  the  only  two  eyes 
that  required  enucleation  during  the  patient's  stay  in  the  hospital 
were  infected  with  a  type  III  organism. 

Summary:  Of  the  ulcers  studied,  66  per  cent,  were  caused  by  a 
type  IV  organism  and  33  per  cent,  by  a  type  III  organism. 

The  failure  of  serum  in  pneumococcus  ulcers  of  the  cornea  is  ade- 
quately explained  by  the  fact  that  none  of  the  organisms  are  of 
type  I. 

The  present  pneumococcus  sera  obtainable  have  little,  if  any, 
specific  action  on  organisms  in  the  cornea  and  absolutely  no  benefit  is 
to  be  expected  from  their  use. 

That  the  type  IV  pneumococci  found  in  the  cornea  belong  to  one 
definite  sub-group  for  which  there  may  be  a  specific  serum,  is  possible 
but  not  probable. 

In  conclusion,  I  wish  to  thank  Dr.  G.  S.  Derby  and  Dr.  F.  H. 
Verhoeff  for  their  kindness  in  giving  me  valuable  suggestions  and  in 
allowing  me  to  report  their  cases. 

DISCUSSION 

DR.  GEORGE  S.  DERBY  (Boston,  Mass.) :  This  is  an  important  bit  of  re- 
search, because,  according  to  my  knowledge,  it  is  the  first  time  pneumococci 
found  in  the  eye  and  corneal  ulcer  have  been  typed.  It  was  necessary  that 
this  should  be  done.  It  explains  the  failure  of  sera  to  work. 

To  those  who  think  there  is  some  virtue  in  making  bacteriologic  examina- 
tion of  secretions  in  the  conjunctival  sac,  especially  before  cataract  operation, 
the  use  of  Avery  media  is  certainly  to  be  recommended.  It  is  a  compara- 
tively simple  medium  to  make  up,  and  it  will  grow  pneumococci  nearly  every 
time.  Moreover,  it  grows  pneumococci  in  from  six  to  ten  hours,  so  that  you 
can  have  your  patient  come  to  the  hospital  the  night  before,  have  a  culture 
taken,  and  have  your  bacteriologic  report  early  next  morning  before  you  are 
ready  to  operate. 

DR.  R.  C.  CHENEY  (closing):  I  do  not  think  that  serum  treatment  in 
pneumococcus  ulcers  of  the  cornea  will  ever  be  of  value,  even  if  type  I  organ- 
isms are  found.  When  you  consider  the  avascular  character  of  the  cornea,  it 
is  hard  to  conceive  how  you  could  influence  the  process  to  any  great  degree  by 
injection  of  serum  into  the  blood-stream  which  is  conspicuous  by  its  absence 
at  the  site  of  the  lesion. 


L'ETAT  VASCULAIRE  DES  GLAUCOMATEUX  (ETUDE 
DE  100  MALADES  DE  GLAUCOME  PRIMITIF) 

DOCTEUR  CARLOS  CHARLIN 

Charge  de  cours  a  1'Universite  de  Santiago  du  Chile.     Professeur 
extraordinaire  d'Ophtalmologie,  Santiago,  Chile 

Au  mois  d'octobre  de  cette  annee,  nous  avons  envoye  d  la  Societe 
d'Ophtalmologie  de  Paris  un  memoire  sur  1'etat  vasculaire  des 
glaucomateux,  me'moire  fait  en  collaboration  avec  notre  e'le've,  le 
Docteur  Cristobal  Espildora. 

Nous  avions  reuni  au  hasard  de  leur  arrivee  d  notre  consultation 
75  observations  de  glaucomes  primitifs  ou  les  malades  etaient  etudies 
au  point  de  vue  general,  surtout  au  point  de  vue  cardio-vasculaire. 

Depuis  lors,  nous  avons  poursuivi  notre  etude  et  ce  sont  les  25 
nouvelles  observations  reunies,  que  nous  presentons  au  Congres 
International  d'Ophtalmologie  de  Washington  de  1922. 

Ce  nouveau  materiel  clinique  accumule  a  confirme  dans  les  grandes 
lignes  les  conclusions  de  notre  premier  me'moire. 

Nous  faisons  prece"der  ces  25  observations  d'un  resume,  de  1'exposi- 
tion  de  la  matiere  contenue  dans  cette  premiere  communication  faite 
d  la  Societe  francaise  d'Ophtalmologie  de  Paris. 

Dans  les  25  dernieres  observations  nous  avons  e"tudie  plus  min- 
utieusement  nos  malades : 

(a)  Nous  avons  insiste  davantage  sur  1'examen  des  urines. 

(b)  Nous  avons  mesure  a  plusieurs  reprises,  en  diffe'rentes  seances, 
la  pression  arte>ielle  quand  la  normalite  de  celle-ci  se  pretait  a  des 
doutes. 

(c)  Nous  avons  fait  la  Reactivation  de  la  Reaction  de  Wasser- 
mann  (methode  de  Millian)  quand  celle-ci  etait  negative,  malgre  des 
antecedents  suspects.1 

(d)  Nous  avons  complete  notre  examen  clinique  par  une  amnese 
generale,  aussi  souvent  que  cela  a  e^e*  possible. 

1  Nous  faisons  la  Reactivation  en  injectant  %  eg.  de  cyanure  de  mercure 
intraveineux  tous  les  2  jours;  apres  la  Seme  injection,  nous  refaisons  le  jour 
suivant  la  Reaction  de  Wassermann. 

383 


384  CARLOS  CHARLIN 

I.   LES  ALTERATIONS  VASCULAIRES  CHEZ  LES  GLAUCOMATEUX 
Qu'avons-nous  trouve  sur  les  100  premiers  malades  examines: 

90  malades  avec  des  alte"rati6ns  cardio-vasculaires; 
3      id.       sans  alterations  cardio-vasculaires  perceptibles,  mais 

avec  Reaction  de  Wassermann  positive; 
7      id.       avec  examen  cardio-vasculaire  et  serologique  negatif. 

Nous  nous  empressons  de  dire  que  tons  les  cas  ne  se  pre"sentaient 
pas  sous  un  type  clinique  de"fini,  de  constatation  et  de  diagnostic 
faciles — ainsi,  chez  quelques-uns,  1'affection  vasculaire  aurait  passe 
inapergue  sans  la  manometrie,  la  radioscopie,  la  sphygmographie  et 
1'examen  des  urines. 

Chez  la  grande  majorite",  au  contraire,  la  lesion  aortique,  1'hyper- 
tension  arterielle  ne  pouvaient  rester  meconnues,  meme  a  un  examen 
superficiel. 

La  localisation  clinique  predominante  a  e"te  1'aortite  et  1'hyperten- 
sion  arte*rielle.  L'aorte  est  malade  59  fois  sur  100  cas,  15  fois  1'aortite 
chronique  etait  accompagne"e  d'insuffisance  valvulaire,  5  fois  de  re"- 
tre"cissement  aortique  pur  et  1  fois  de  retrecissement  et  d'insuffisance 
simultane'e.  (obs.  18.) 

L'aortite  s'est  souvent  presentee  silencieuse  sans  symptomes  sub- 
jectifs. 

L'hypertension  arte"rielle  est  encore  plus  frequente  (62  fois  sur  100 
malades). 

Le  compromis  du  rein  constatable  par  un  examen  d'urine  anormal 
(faible  densite  et  indices  d'albumine)  n'est  pas  tres  frequent.  Mais 
si  nous  devons  interpreter  1' augmentation  de  la  pression  systolique 
comme  un  signe  de  sclerose  renale,  nous  devons  admettre  que  le  rein 
a  du  etre  touche  bien  plus  souvent  et  qu'une  etude  plus  approfondie 
de  la  fonction  de  la  glande  nous  aurait  permis  de  constater,  chez 
beaucoup  de  malades,  la  nephrite  chronique  ebauche'e. 

En  effet,  au  commencement  de  notre  e"tude,  la  grande  majorite" 
des  examens  d'urine  ont  e^e"  tre"s  superficiels  et  absolument  insuffi- 
sants. 

La  discordance  entre  Pexamen  re"nal  et  I'examen  vasculaire  de  nos 
65  premieres  observations  nous  a  surpris  et  un  peu  de*routes. 

Dans  les  observations  posterieures,  1'etude  de  1'e'limination  urinaire 
a  etc"  plus  complete  et  nous  avons  trouve  ce  qui  nous  faisait  supposer 
l'£tat  vasculaire  anormal:  le  compromis  frequent  du  rein.  La 


L'Etat  Vasculaire  des  Glaucomateux  385 

nephrite  chronique  fruste  se  pre'sente  Ire's  souvent  chez  le  glauco- 
mateux. 

En  tout  cas,  ces  62  malades,  ce  62%  d'hypertension  systolique 
parle  de  la  grande  frequence  de  la  sclerose  vasculaire  peripherique 
chez  les  glaucomateux. 

La  pression  diastolique  ou  minima  6tait  augmentee  chez  quelques 
malades  d'une  facon  manifeste. 

La  myocardite  a  e"te  constatee  5  fois. 

A  noter  5  malades  avec  lesion  mitrale. 

Le  diabete  s'est  present^  3  fois  et  accompagne  d'aortite  et  d'hyper- 
tension arte"rielle. 

L'emphyseme  et  la  sclerose  pulmonaire  n'ont  pas  ete  rares. 

La  tuberculose  pulmonaire  n'a  ete  observed  en  periode  d'activite1 
qu'une  seule  fois.  (obs.  91.) 

Les  ganglions  bronchiaux  ont  ete  deceles  frequemment  a  I'examen 
radioscopique. 


II.    ETIOLOGIE  DE  L' ALTERATION  VASCULAIRE  GENERALE  CHEZ  LES 

GLAUCOMATEUX 

Nous  avons  dit  que  sur  nos  100  malades,  90  presentaient  des  al- 
terations de  1'appareil  vasculaire. 

De  ces  90,  59  avaient  1'aorte  anormale  et  62  de  1'hypertension 
arterielle. 

Les  auteurs  indiquent  comme  cause  des  lesions  vasculaires  chroni- 
ques  et  specialement  des  aortites,  les  infections  et  intoxications,  par 
exemple  la  syphilis,  Palcoolisme,  la  senilite,  la  goutte  et  le  paludisme. 
De  ces  facteurs,  nous  pouvons  eliminer  la  goutte  et  le  paludisme, 
maladies  exceptionnelles  au  Chili,  veYitables  trouvailles  cliniques 
(nous  n'en  avons  rencontre  aucun  cas  parmi  nos  glaucomateux). 

La  syphilis  et  1'alcoolisme  sont  au  contraire  d'une  extreme  frequence, 
surtout  la  premiere  de  ces  affections. 

II  ne  serait  pas  tr6s  aventure  de  supposer  qu'une  grande  part  de 
1'action  de  1'intoxi cation  etylique  soit  due  a  la  syphilis,  que  1'on  trouve 
souvent  chez  les  antecedents  d'un  alcoolique. 

La  senilit^  a  une  influence,  semble-t-il,  plus  secondaire  que  la 
syphilis,  puisque  entre  nos  100  glaucomateux,  41  seulement  sont 
entres  dans  1'age  se'nile,  ayant  depasse1  les  60  ans,  et  entre  ces  41,  11 
e"taient  surement  et  3  probablement  syphilitiques. 

Le  Glaucome  s'est  present^: 
25 


386 


CARLOS  CHARLIN 


De  moins  de  30  ans 1  f  ois 

De  31  a  40  ans 2 

De  41  a  50  ans 26 

De51  £60  ans 30 

De61  a  70  ans 31 

De  71  a  80  ans 9 

De  81  a  90  ans 1 

100  malades:  35  hommes,  65  femmes. 

En  tenant  compte  des  deux  grands  facteurs  e"tiologiques  de  1'affec- 
tion  de  1'appareil  vasculaire,  la  syphilis  et  la  senilite,  de  beaucoup  les 
plus  importants,  nous  sommes  arrives  a  se*parer  nos  malades  en  4 
groupes : 

1.  Glaucomateux  avec  arteriopathies  syphilitiques  que  nous  de- 
signerons  sous  1'expression  ' '  glaucomateux  syphilitiques. ' '     (Page  11.) 

2.  Glaucomateux  non  syphilitiques  avec  lesions  arteriosclereuses, 
que  nous  de*signerons  sous  Texpression  "glaucomateux  arte'rioscler- 
eux."     (Page  28.) 

3.  Glaucomateux    avec    affections    cardio-vasculaires    d'etiologie 
diverse.     (Page  37.) 

4.  Glaucomateux  d  examen  general  negatif.     (Page  39.) 

TABLEAU  GENERAL.     GLAUCOMATEUX 


Total 

Syphili- 
tiques 

Arterio- 
sclereux 

? 

N6gatifs 

De  moins  de  30  ans  

1 

1 

De  31  a  40  ans  

2 

1 

1 

De  41  &  50  ans  

26 

22 

4 

De  51  £  60  ans    

30 

20 

8 

2 

De  61  a  70  ans        

31 

9 

18 

4 

De  71  £  80  ans          

9 

4 

5 

De  81  £  90  ans  

1 

1 

100 

57 

32 

4 

7 

III.  GLAUCOMATEUX  SYPHILITIQUES 

(57  Gas) 

Des  100  glaucomateux  etudie*s,  46  e"taient  surement  syphilitiques  et 
11  tre"s  suspects,  ce  qui  donne  un  haut  pourcentage  de  pres  de  60%. 
Le  Glaucome  s'est  pre'sente'  chez  des  syphilitiques: 

De  moins  de  30  ans 1  fois 

De  31  a  40  ans 1 

De41  d  50  ans 22 

De  51  a  60  ans 20 

De  61  a  70  ans..  , 9 

De  plus  de  70  ans _4_ 

Total .  .  . .  57~ 


L'Etat  Vasculaire  des  Glaucomateux  387 

Sur  le  total  des  100  glaucomateux,  29  n'avaient  pas  de'passe'  la 
cinquantaine  et  de  ces  29,  24  etaient  syphilitiques  et  5  seulement 
apparemment  etaient  libres  de  1'affection  venerienne. 

Nous  croyons  que  .cette  constatation  doit  etre  soulignee  parce 
qu'elle  a  une  certaine  portee  pratique. 

Notre  petite  statistique  dit :  le  glaucomateux  de  moins  de  50  ans,  le 
glaucomateux  jeune,  est  presque  tou jours  syphilitique. 

II  nous  semble  que  ce  resultat  statistique  n'est  pas  un  simple  effet 
du  hasard,  mais  naturellement  cette  affirmation  a  besoin,  pour  ac- 
querir  sa  veritable  valeur,  qu'une  observation  etendue  a  un  plus  vaste 
materiel  clinique,  la  confirme. 

Des  57  glaucomateux,  consideres  par  nous  comme  syphilitiques 
ou  tres  suspects  de  syphilis,  32  avaient  une  Reaction  de  Wassermann 
positive,  1  etait  heredosyphilitique,  13  avaient  des  antecedents 
specifiques  non  discutables,  11  seulement  sur  ces  57  sont  des  cas  pro- 
bables, tres  probables,  mais  non  prouves. 

Entre  les  32  malades  avec  Reaction  de  Wassermann  positive :  3  ne 
presentaient  aucun  symptome  cardio-vasculaire,  4  seulement  une 
image  radioscopique  anormale,  2  une  insuffisance  mitrale  (obs.  12  et 
84)  et  23  de  1'hypertension  arterielle  ou  de  1'aortite,  etc. 

Le  compromis  du  myocarde  a  e"te  observe  5  fois  chez  les  syphiliti- 
ques. 

Des  18  glaucomateux,  consideres  comme  syphilitiques,  mais  avec 
Reaction  de  Wassermann  negative,  9  avaient  de  1'aortite  chronique, 
compliquee  d'insuffisance  valvulaire  sygmoidienne,  aortite  du  type 
syphilitique;  5  de  1'aortite  et  de  1'hypertension  arterielle  avec  des 
antecedents  specifiques  non  discutables,  1  avait  de  1'aortite  et  pre- 
sentait  simultanement  de  la  nevrite  optique  syphilitique  a  1'oeil  de 
tension  normale  (obs.  46),  1  de  1'aortite  et  un  retrecissement  aortique 
(obs.  79)  1  de  1'aortite  et  de  la  nephrite  (obs.  81)  et  1  de  1'hyperten- 
sion  arterielle  (obs.  78). 

Le  diabete  a  etc"  observe  2  fois.     (Obs.  91  et  96.) 

Sur  le  total  de  57  malades  1'aortite  a  ete  signalee  42  fois,  avec  lesion 
valvulaire  18  cas;  1'hypertension  arterielle  37  fois. 

Entre  ces  57  observations,  nous  avons  rencontre  5  fois  le  glaucome 

aigu. 

f  1.  Glaucomateux   syphilitiques    avec    Reaction    de    Wasser- 
mann positive. 
2.  Glaucomateux  syphilitiques  avec  Reaction  de  Wassermann 


GLAUCOMATEUX 
SYPHILITIQUES 


negative. 
3.  Glaucomateux  suspects  de  syphilis. 


388  CARLOS  CHARLIN 

1.  GLAUCOMATEUX  AVEC  REACTION  DE  WASSERMANN  PosiTiVE.1 — 
Les  observations  contenues  dans  ce  Me"moire  apparaissent  soulignees. 

(a)  Sans  manifestations  vasculaires  ge'ne'rales  perceptibles;    obs. 
11,  16,  82. 

(b)  Avec  image  radioscopique  cardio-aortique  anormale;    obs.  6, 
9,51. 

(c)  Avec  symptomes  vasculaires  ge'ne'raux  frustes  (legere  hyper- 
tension arterielle) ;  obs.  8,  25,  93. 

(d)  Avec  insuffisance  mitrale  et  dilatation  du  coeur;  obs.  12. 

(d')  Avec  insuffisance  mitrale  et  hypertension  arterielle;   obs.  84  • 

(e)  Avec  aortite  et  sphygmogramme  avec  plateau;  obs.  32,  45,  71. 

(f)  Avec  aortite  et  hypertension  arterielle;  obs.  39,  54,  92,  98, 100. 

(f )  Avec  aortite,  hypertension  arterielle  et  diabete;  obs.  96. 

(g)  Avec  aortite  et  myocardite;  obs.  41,  95. 
(g')  Avec  myocardite;  obs.  99. 

(h)  Avec  aortite,  re'trecissement  aortique,  hypertension  arterielle 
et  insuffisance  mytrale;  obs.  66,  53. 

(k)  Avec  aortite,  insuffisance  aortique  et  hypertension  arterielle; 
obs.  22,  26. 

(1)  Avec  aortite,  insuffisance  aortique,  hypertension  arterielle  et 
myocardite;  obs.  23. 

(m)  Avec  aortite,  arteriosclerose  et  hypertension  arterielle;  obs. 
13,  37,  21,  28. 

2.  GLAUCOMATEUX  SYPHILITIQUES  AVEC  REACTION  DE  WASSER- 
MANN NEGATIVE. 

(a)  Avec  aortite  du  type  syphilitique  complique'e  d 'insuffisance 
valvulaire  sygmoidienne :  (I)  Sans  hypertension  arterielle;  obs.  50; 
(II)  Avec  hypertension  arterielle,  obs.  20,  30,  34,  52,  57,  86,  87. 

{b)  Avec  aortite  du  type  syphilitique  avec  insuffisance  et  re'tre'cis- 
sement  aortique  et  hypertension  arterielle;  obs.  18. 

(c)  Avec  aortite,  sans  lesions  valvulaires,  avec  hypertension  ar- 
terielle et  antecedents  cliniques  de  syphilis;  obs.  19,  31,  40,  63. 

(d)  Avec  symptomes  aortiques  et  avec  une  lesion  syphilitique  en 
pleine  Evolution;  obs.  46. 

3.  GLAUCOMATEUX  AVEC  SYMPT6MES  VASCULAIRES  ET  SUSPECTS 
DE  SYPHILIS. 

(a)  Avec  symptomes  d'arterioscierose  pe"ripherique  apparus  pre- 
cocement;  hypertension  arterielle;  obs.  14. 

1  Les  observations  de  1  d  75  forment  partie  du  M6moire  present^  a  la  Soci£t£ 
d'Ophtalmologie  de  Paris. 


•       L'Etat  Vasculaire  des  Glaucomateux  389 

(b)  Avec  hypertension  arte"rielle;  obs.  78. 

(c)  Avec  symptomes  cardio-aortiques  et  ancienne  Irite;  obs.  3. 

(d)  Avec  aortite  et  nephrite  chronique;  obs.  87. 

(e)  Avec  aortite  et  hypertension  arte"rielle  d  50  ans;  obs.  4. 

(f)  Avec  aortite,  hypertension  arterielle  et  diabete;  obs.  91. 

(g)  Avec  aortite  et  retrecissement  aortique;  obs.  79. 
(h)  Avec  aortite  et  insuffisance  aortique;  obs.  42. 

(i)  Avec  aortite,  insuffisance  aortique,  hypertension  arterielle  et 
myocardite;  obs.  48. 

(k)  Avec  aortite,  insuffisance  aortique,  hypertension  arterielle; 
obs.  56. 

(1)  Avec  hypertension  arterielle,  nephrite  chronique  et  symptomes 
aortiques  a  44  ans;  obs.  55. 

I.   OBSERVATIONS  DE  GLAUCOMATEUX  SYPHILITIQUES 
1.  AVEC  REACTION  DE  WASSERMANN  POSITIVE. — (a)  Sans  Symp- 
tdmes    Cardiovasculaires    Perceptibles.     Obs.    82    (No.    5661)    (No. 
d'ordre  de  la  clinique). 

Rosa  A.,  femme,  55  ans.  Diagn.  ophtalm. :  0.  D.,  glaucome  absolu;  0.  G., 
glaucome  chronique.  Diagn.  clinique:  Syphilis. 

Examen  oculaire  (Juillet,  1921) ;  O.  D.,  corne"e  opacifie"e  dans  son  %  inferieur ; 
chambre  ant&ieure  aplatie;  pupille  mydriatique  immobile;  iris  atrophique; 
opacite"  totale  du  cristallin.  Vision  =  0.  Tension  +  2.  0.  G.,  chambre 
ante>ieure  aplatie;  pupille  mydriatique  moyenne,  sans  reactions;  excavation 
glaucomateuse  profonde,  mais  rose"e.  Vision,  perception  lumineuse.  Tension 
+  2. 

Examen  clinique:  Pointe  du  coeur  au  5e"me  espace  intercostal,  ligne  mamil- 
laire;  26me  bruit  aortique  renforce'.  Pression  arterielle  (Pachon):  MX.  15; 
Mn.  7.  Radioscopie:  Coeur  Ie"g6rement  augment^  de  volume — Aorte 
normale.  Urine:  Densite"  1016:  indices  d'albumine;  peu  d'indican  et  traces 
d'urobiline.  Ur^e  7.80  %;  chlorures  9.0%;  au  microscope:  peu  de  globules 
blancs,  de  cellules  e'pithe'liales  polygonales  et  rondes.  Sang:  Ur6e  0.20%. 
Reaction  de  Wassermann  positive. 

(6)  Avec  Symptdmes  Cardiovasculaires  Frustes.     Obs.  93  (No.  5754). 

Fidelisa  J.,  48  ans,  femme.  Diagn.  ophtalm.:  0.  D.,  glaucome  aigu;  0.  G., 
idem.  Diagn.  clinique:  Syphilis. 

Examen  oculaire  (Aout,  1921):  0.  D.,  injection  bulbaire,  corne"e  trans- 
parente,  normale,  pupille  en  mydriase  moyenne,  immobile;  fond  pas  ex- 
aminable.  Vision,  0.  D.,  compte  les  doigts  d  40  cm.  Tension,  Schiotz 
1/10  =  70  mm.  0.  G.,  injection  bulbaire,  corne"e  de  surface  chagrine'e; 


390  CARLOS  CHARLIN 

pupille  mydriatique,  immobile,  fond  pas  examinable.  Vision,  mouvements 
de  la  main  a  0  m.  50.  Tension,  Schiotz  1  /10  =  70  mm. 

8  Aout:  Iridectomie  antiglaucomateuse  O.  D.  en  bonnes  conditions  sous 
anesthe"sie  locale. 

18  Aout:  Vision,  O.  D.  5/30.  Tension  =  1  ou — 1.  Iridectomie  anti- 
glaucomateuse O.  G.  sans  incidents,  sous  anesthe"sie  locale  (Duverger). 

8  Sept.:  Vision,  O.  D.  5/15;  O.  G.  5/40.  Tension,  0.  D.  8/7.5  =  16  mm. 
(Schiotz);  O.  G.  12/7.5  =  9  mm. 

22  Sept.:  Vision,  0.  D.  5/10;  0.  G.  5/30.  Tension,  Schiotz,  O.D.  8/7.5  = 
18  mm.;  0.  G.  6/7.5  =  23  mm. 

Examen  clinique:  Renforcement  du  2e"me  bruit  aortique.  Pression  arte- 
rielle  (5  Aout)  Pachon,  MX.  16.5  Mn.  8;  pression  arte'rielle  (6  Sept.)  Pachon, 
MX.  16.5  Mn.  10.5;  pression  arte'rielle  (22  Sept.)  Pachon,  MX.  17  mm. 
Mn.  11  mm.  Radioscopie  thoracique  negative.  Reaction  de  Wassermann: 
positive.  Urine:  examen  ne"gatif.  (Densite"  1016 — Ure"e  9.10%;  chlorures 
9.8%;  pas  d'albumine,  pas  d'e'le'ments  figures.  Liquide  ce"phalo-rachidien : 
examen  ne"gatif. 

Antecedents:  3  avortements,  6  enfants  de  terme,  1  mortus  nato  dans  une 
grossesse  ge"mellaire — 2  fils  sont  morts. 

(c)  Avec  insuffisance  Mitrale  et  Hypertension  Arterielle.     Obs.  84 
(No.  5658). 

Pedro  H.,  65  ans,  homme.  Diagn.  ophtalm. :  O.  D.  G.,  glaucome  chronique. 
Diagn.  clinique  (Dr.  J.  Rodriguez) :  Insuffisance  mitrale,  hypertension  arte'- 
rielle, arythmie  extrasystolique — Syphilis. 

Examen  oculaire  (Juillet,  1921) :  Est  malade  des  yeux  depuis  deux  ans. 
0.  D.,  pterigion — chambre  anterieure  le"gerement  aplatie;  pupille  immobile 
en  mydriase  moyenne;  opacite  diffuse  du  cristallin,  empeche  examen  ophtalmo- 
scopique.  Vision  =  0.  Tension  +  2.  0.  G.,  le'ge're  opacite  corne"enne 
quadrant  inf. -interne;  pupille  immobile  mydriatique — Profonde  excavation 
papillaire  glaucomateuse  atrophique.  Vision,  perception  lumineuse.  Ten- 
sion +  2. 

Examen  clinique:  Arytmie  extrasystolique — Le'ge're  insuffisance  mytrale. 
Pression  arte'rielle:  MX.  21;  Mn.  11.  Radioscopie:  Coeur  augmente  de 
volume.  Reaction  de  Wassermann  negative.  Apres  3  injections  intra- 
veineuses  de  cyanure  (en  6  jours)  elle  devient  positive.  Examen  d'urine: 
Densite"  1022,  indices  d'albumine  et  d'urobiline,  ure"e  19.51%;  chlorures 
11.4%;  quelques  globules  blancs  et  rouges,  quelques  cellules  e'pithe'liales 
polygonales  et  rondes. 

(d)  Avec  Aortite,  Hypertension  Arterielle.     Obs.  92  (No.  5724). 
Rosario  R.  60  ans,  femme.    Diagn.  ophtalm.:  0.  D.,  anophtalmie  ope"ra- 

toire;  O.  G.,  glaucome  inflammatoire  chronique.  Diagn.  clinique  (Dr. 
Borquez) :  Syphilis — Hypertension  arte'rielle,  aortite — Nephrite  chronique. 


L'Btat  Vasculaire  des  Glaucomateux  391 

Examen  oculaire  (Juillet,  1921):  0.  G.,  injection  pericorn^ale;  corn^e  de 
surface  chagrine"e;  chambre  anterieure  aplatie;  pupille  mydriatique  immo- 
bile; fond  pas  examinable.  Vision,  perception  lumineuse.  Tension  +  2. 

Examen  clinique:  Battements  arteriels  suprasternaux  et  supraclaviculaires 
— choc  de  la  pointe  du  coeur  violent  au  5e"me  espace  intercostal  (e*re*thisme 
cardiaque).  Pression  arterielle  (Potain):  MX.  26;  au  autre  jour  (Pachon): 
MX.  22;  Mn.  12.  Radioscopie:  Crosse  aortique  dilatee.  Reaction  de 
Wassermann  negative;  reactivation  positive.  Urine:  Densite  1016;  al- 
bumine  0.10.  Ur^e  9.10;  chlorures  8.8;  quelques  globules  rouges,  cellules 
epitheliales  polygonales  et  rondes.  Sang:  Uree  0.25%. 

Antecedents:  Souffre  fre"quemment  de  cephaiees,  douleurs  rheumatoides, 
troubles  gastriques — pas  de  grossesses. 

Obs.  98  (No.  5850) 

Louisa  S.,  74  ans,  femme.  Diagn.  ophtalm.:  0.  D.  G.,  glaucome  absolu. 
Diagn.  clinique:  Aortite — Hypertension  arterielle — Nephrite  chronique — 
Syphilis. 

Examen  oculaire:  0.  D.,  pupille  mydriatique  immobile,  cristallin  opacifie. 
Vision  =  0.  Tension  +  1;  Schiotz  3/7. 5  =  36  mm.  0.  G.,  pupille  mydria- 
tique immobile;  excavation  papillaire  glaucomateuse  atrophique,  halo  pe*ri- 
papillaire.  Vision  =  0.  Tension  +  1 ;  Schiotz  4  /7.5  =  31  mm. 

Examen  clinique:  Aorte  haute  et  elargie;  renforcement  du  2eme  bruit 
aortique — Pouls  108.  Pression  arterielle  (Pachon) :  MX.  27;  Mn.  16.  Radio- 
scopie: Aorte  ascendante  et  descendante  augmentee  uniformement.  La 
crosse  de"passe  la  clavicule.  Grande  hypertrophie  du  ventricule  gauche. 
Reaction  de  Wassermann  positive.  Urine:  Densite  1017;  indices  d'  albumine. 
Ur6e  11.53%;  chlorures  9.0%;  assez  de  globules  blancs,  quelques  globules 
rouges  et  cellules  epitheliales  polygonales.  Sang:  Uree  0.60%.  Sphygmo- 
gramme:  tendance  au  plateau. 

Antecedents :  Personnels :  sans  importance. 

Obs.  100  (No.  5896) 

Maria  FL,  50  ans,  femme.  Diagn.  ophtalm.:  0.  D.,  atrophie  bulbaire; 
O.  G.,  glaucome  absolu.  Diagn.  clinique  (Dr.  Borquez) :  Aortite,  Nephrite 
chronique,  Hypertension  arterielle — Syphilis. 

Examen  oculaire:  O.  D.,  bulbe  oculaire  atrophique.  0.  G.,  vaisseaux 
ciliaires  anterieurs  dilates;  -chambre  anterieure  aplatie;  pupille  en  mydriase 
moyenne,  immobile;  fond  pas  examinable.  Vision  =  0.  Tension  +  3; 
Schiotz  0/7.5  =  60  mm. 

Examen  clinique:  Bruit  aortique  exagere  et  systole  un  peu  obscur — • 
Battements  suprasternaux  et  supraclaviculaires.  On  sent  1'aorte  derriere  la 
fourchette  sternale.  Pression  arterielle  (Pachon):  MX.  22;  Mn.  11;  pouls 
78;  respiration  18  par  minute.  Radioscopie:  Aorte  tres  haute  et  obscure, 


392  CARLOS  CHARLIN 

legerement  plus  grosse — Hypertrophie  du  ventricule  gauche — Scle"rose 
peribronchiale.  Reaction  de  Wassermann  negative;  reactivation  (apres  3  in- 
jections de  mercure)  positive.  Urine:  Densite"  1014;  albumine  0.20.  Ur6e 
8.96%;  chlorure  7.0%. 

Antecedents:  Mari  mort  1'annee  pass^e  a  1'age  de  40  ans  avec  une  hemi- 
piegie  gauche.  1  avortement,  3  enfants  vivants. 

(e)  Avec  Aortite,  Hypertension  Arterielle  et  Diabete.  Obs.  96  (de 
la  clientele  privet). 

Calixto  P.,  72  ans,  homme.  Diagn.  ophtalm.:  0.  D.,  aphaquie  operatoire, 
glaucome  absolu.  Diagn.  clinique:  Diabete — Hypertension  arterielle — 
Aortite  chronique — Syphilis. 

Examen  oculaire  (Dec.,  1920):  O.  D.,  colobome  de  1'iris  operatoire; 
chambre  anterieure  profonde;  aphakie;  excavation  papillaire  glaucoma- 
teuse  avec  halo  peri  papillaire.  Vision  =  0.  Tension  +  2.  0.  G.,  opacite 
diffuse  nucieaire  initiale  du  cristallin,  papille  normale;  pupille  et  reaction 
pupillaire  normales.  Vision  5/50.  Tension  =  1. 

(Novembre,  1921):  0.  D.,  idem  examen  anterieur.  Vision  =  0.  Tension 
+  1;  Schiotz  5 /7. 5  =  26  mm.  O.  G.,  opacite  du  cristallin  partielle.  Vision 
1/50.  Tension  =  1;  Schiotz  7/7.5  =  18  mm. 

Examen  clinique  (Novembre,  1921):  On  touche  1'aorte  derriere  la  four- 
chette  sternale.  Pression  arterielle:  (7  Nov.)  Pachon:  MX.  21;  Mn.  9; 
pouls  72.  (16  Nov.)  Pachon:  MX.  23;  Mn.  8.  Radioscopie  (Dr.  Ducci): 
Aorte  augmentee  dans  ses  trois  dimensions — gros  coeur.  Reaction  de  Wasser- 
mann positive.  Urine:  Glucose  8.54%. 

Antecedents:  A  ete  op6re  de  cataracte  0.  D.  en  1914,  mais  apres  1'opera- 
tion,  la  vue  ne  s'etait  guere  ameiioree.  Souffre  d'otite  moyenne  et  salpingite 
catarrhale  bilaterale.  (Dr.  J.  Castro.) 

(/)  Avec  Myocardite.     Obs.  99  (No.  5880). 

Elias  M.,  45  ans,  homme.  Diagn.  ophtalm.:  0.  G.,  panophtalmite  second- 
aire  a  une  ancienne  iridectomie  antiglaucomateuse;  0.  D.,  glaucome  absolu. 
Diagn.  clinique  (Dr.  Rodriguez) :  Myocardite  chronique — Syphilis. 

Examen  oculaire:  II  y  a  quelques  annees  a  ete  opere  des  deux  yeux  pour 
glaucome.  0.  D.,  colobome  operatoire  de  1'iris;  excavation  papillaire 
glaucomateuse  atrophique.  Vision  =  0.  Tension  +1.  0.  G.,  oedeme 
palpebral;  injection  bulbaire  et  quemosis  conjonctivale;  la  conjonctive  aux 
environs  de  XII  montre  une  tumeur  jaunatre;  reflet  vert  jaunatre  de  la 
pupille;  Fond  pas  examinable.  Vision  =  0.  Tension  +  2;  Schiotz  0/7.5 
>  60  mm. 

31  Aout:  0.  D.,  exenteration  oculaire  avec  anesthesie  locale,  injection  2 
cc3  de  novocaine  3%,  retro-oculaire — abces  du  vitre. 


L'fitat  Vasculaire  des  Glaucomateux  393 

Examen  clinique:  Aorte  normale;  Tachy cardie  (pouls  120);  Arythmie, 
respiration  17  par  minute;  temperature  36°2.  Pression  arterielle :  MX.  14.5; 
Mn.  1 1  (Pachon) :  Sphygmogramme  athe>omateux  (plateau) .  Pouls  apr6s 
quelques  jours  de  digitale :  tachy cardie  et  arythmie.  Reaction  de  Wassermann 
negative;  reactivation  (apres  3  injections  mercurielles)  positive.  Urine: 
indices  d'albumine.  Sang:  Ure"e  0.35  %. 

Antecedents:  La  femme  a  eu  4  avortements,  3  enfants  morts  dans  la 
premiere  enfance,  5  enfants  vivants,  sains. 

(g)  Avec  Myocardite  et  Aortite.     Obs.  95  (No.  5817). 

Anastasie  T.  59  ans,  femme.  Diagn.  ophtalm.:  0.  D.,  glaucomechronique; 
0.  G.,  glaucome  absolu. 

Diagn.  clinique  (Dr.  J.  Rodriguez):  Myocardite  chronique — Aortite 
chronique — Nephrite  chronique  hydrurique — Emphyseme  et  scierose  pul- 
monaire — Syphilis. 

Examen  oculaire  (Aout,  1921):  O.  D.,  cornee  de  surface  chagrinee;  cham- 
bre  anterieure  aplatie;  pupille  mydriatique ;  immobile;  fond  pas  examinable. 
Vision,  perception  lumineuse.  Tension  +  2;  Schiotz  2 /7. 5  =  60  mm.  0.  G., 
injection  pericorneale;  cornee  chagrinee ;  chambre  anterieure  effacee ;  pupille 
mydriatique  immobile;  opacite  totale  du  cristallin.  Vision  =  0.  Tension 
+  2;  Schiotz  1/7.5  =  70  mm. 

Examen  clinique:  Aorte  legerement  elevee,  eiargie,  pouls  frequent  96  p. 
avec  intermittences.  Pression  arterielle  (Pachon):  MX.  15;  Mn.  8.5. 
28  Aout:  2eme  medition:  MX.  17.5;  Mn.  10.5.  6  Sept.:  MX.  15;  Mn.  9; 
pouls  120,  respiration  29,  tachycardie  et  arythmie.  15  Sept.:  Apres  3  jours 
de  digitale  et  de  theobromine.  Pression  arterielle:  MX.  16;  Mn.  9,  pouls  100 
arythmie.  20  Sept.:  Apr6s  1  gramme  de  digitale:  MX.  12;  Mn.  6.5;  pouls 
112,  arythmie.  Radioscopie  negative;  reaction  de  Wassermann  negative; 
reactivation  (avec  3  injections  de  cyanure  de  Hg  en  6  jours)  positive.  Urine: 
quantite  2050  en  24  heurs;  densite  1012;  indices  d'albumine;  uree  7.08, 
chlorures  6.6%;  quelques  rares  globules  blancs  et  cellules  epitheiiales  poly- 
gonales.  Sang:  UreeO.15%.  Li quide  cephalorachidien  normal. 

Antecedents:  personnels:  pas  d'avortements;  11  enfants  desquels,  8  morts 
dans  la  premiere  enfance. 

2.  GLAUCOMATEUX  SYPHILITIQUES. — Avec  Reaction  de  Wassermann 
Negative.  Anciens  syphilitiques  traites. 

(a)  Aortite,  insuffisance  Aortique,  Hypertension  Arterielle.  Obs. 
86  (No.  5690). 

Carlota  N.,  55  ans,  femme.  Diagn.  ophtalm.:  0.  G.,  glaucome  incipient. 
Diagn.  clinique  (Dr.  Garavagno) :  Diabete,  aortite  avec  insuffiance  aortique 
— Hypertension  arterielle — Nephrite  chronique — Ancienne  syphilitique. 


394  CARLOS  CHARLIN 

Examen  oculaire  (Juillet,  1921) :  Depuis  3  mois  irritation  intermittente  de 
O.  G.  O.  D.  G.,  examen  n^gatif.  (A  1'oeil  droit,  pres  de  la  papille,  il  y  a  une 
tache  blanche  ros£e,  tres  suspecte  .  .  .  Retinite?)  Vision,  O.  D.,  0.  G. 
5/10.  Tension,  Schiotz:  0.  D.  7/7.5  =  18  mm.  0.  G.  4/7.5  =  31  mm. 

Examen  cardiovasculaire:  Coeur  augment^  de  volume,  on  touche  1'aorte 
derrie're  la  fourchette  sternale — souffle  diastolique  au  2^me  espace  intercostal 
droit.  Pression  arterielle  (Pachon):  MX.  26;  Mn.  11.  Radioscopie:  Aorte 
haute  et  grosse — Hypertrophie  du  ventricule  gauche.  Reaction  de  Wasser- 
mann  negative  (apres  des  injections  de  Mercure).  Examen  d'urine:  Densite* 
1033;  albumineO.20%;  glucose  76.44% ;  acetonaO.09;  ur^e  28.62;  chlorures 
l6.2 ;  indices  d'urobiline;  au  microscope:  rien  de  pathologique. 

Antecedents:  En  differentes  occasions  a  fait  quelques  series  de  piqures  de 
mercure. 

Obs.  87  (No.  5818) 

Jose"  M.  57  ans,  homme.  Diagn.  ophtalm.:  0.  G.,  glaucome  de'gene'ratif; 
O.  D.:  glaucome  incipient.  Diagn.  clinique  (Dr.  Mardones):  Syphilis — 
Insuffisance  aortique — Hypertension  arterielle — Paralysie  faciale  droite 
d'origine  centrale. 

Examen  oculaire  (Juillet,  1921) :  0.  D.,  chambre  anteYieure  un  peu  aplatie; 
pupille  et  fond  n^gatifs.  Vision,  0.  D.  5  /5.  Tension,  Schiotz  5  /7.5  =  26  mm. 
Depuis  trois  semaines  seulement  se  plaint  de  douleurs  intermittentes  a 
I'O.  D.  avec  irradiations  aux  dents  de  ce  cote".  O.  G.,  corne*e  en  partie  opaci- 
fiee;  chambre  anterieure  aplatie,  pupille  en  myose  pilocarpinique;  fond  pas 
examinable.  Vision  =  0.  Tension,  Schiotz  0/7.5  =  62  mm. 

Examen  clinique:  Coeur  augmente*  de  volume,  bruits  un  peu  etouffe*s — 
On  touche  1'aorte  derrie're  le  sternum;  souffle  diastolique  aortique — pouls76. 
Pression  arterielle  (Pachon) :  MX.  23;  Mn.  12.  Radioscopie:  Coeur  grand  et 
globuleux;  aorte  assez  grosse  et  obscure,  elle  touche  la  ligne  articulaire  sterno 
— claviculaire — Clavicules  immobiles —  Hiles  pulmonaires  infiltre"s.  Reaction 
de  Wassermann  negative  (a  requ  des  injections  mercurielles) .  Examen  d'urine : 
Densite  1020;  albuminel%;  chlorures  13%;  pas  d'urobiline;  au  microscope : 
rien  de  particulier. 

Antecedents:  A  Page  de  22  ans,  chancre  unique  avec  ganglions  non  supures 
d  1'aine,  un  mois  apr6s  laryngite.  Quelques  mois  plus  tard,  gonorrhee  com- 
pliquee  de  cystite,  prostatite  et  orchite.  Est  arrive  dans  1'annee  dans  un  ser- 
vice de  medecine  interne  avec  dyspn6e  d'effort,  oedeme  des  extremites,  dou- 
leurs retrosternales  tres  failbles,  palpitations  cardiaques.  S'est  alors  ameiiore 
avec  regime  dietatique  et  traitement  iodo  mercuriel.  Se  plaint  de  frequentes 
amnesics  et  de  vertiges. 

3.  GLAUCOMATEUX  SUSPECTS  DE  SYPHILIS. — (a)  Hypertension  Ar- 
terielle. Obs.  78  (No.  5449). 

Franchise  E.,  60  ans,  femme.    Diagn.  ophtalm.:   0.  D.,  glaucome  absolu; 


L'fitat  Vasculaire  des  Glaucomateux  395 

0.  G.,  glaucome  incipient.  Diagn.  clinique  (Dr.  Borquez):  Hypertension 
arterielle,  nephrite  chronique. 

Examen  ophtalm.  (Juin,  1921):  Vision,  0.  D.  =  0;  0.  G.  5/10.  Tension, 
0.  D.  >  62  mm.;  0.  G.,  23  mm.  (Schiotz);  0.  D.,  corne'e  de  surface  chag- 
rine'e;  chambre  anterieure  aplatie;  pupille  deformee,  mydriatique,  immobile; 
fond  pas  examinable.  O.  G.,  chambre  anterieure  aplatie;  pupille  et  fond 
normaux.  19  Juillet:  Tension,  Schiotz  0.  G.  5/7.5  =  26  mm.;  pupille  en 
mydriase  moyenne,  avec  bonnes  reactions;  fond  ne"gatif. 

Examen  clinique  (Drs.  Espildora  et  Borquez):  26me  bruit  aortique  ren- 
force1;  sousclavie'redroitee'levee;  lagers  battements  suprasternaux.  Pression 
arterielle  (Pachon):  MX.  22;  Mn.  15.  Radioscopie:  Aorte  oblique  obscure; 
hypertrophie  du  ventricule  gauche;  pointe  rejet£e  en  dehors.  Condensation 
peribronchiale;  scle>ose  pulmonaire  peu  etendue.  Reaction  de  Wassermann 
egative;  apres  reactivation  negative.  Urine:  Quantity  1700  cc3  en  24  heures; 
densit^  1017;  indices  d'albumine,  peu  d'indican,  traces  d'urobiline.  Ure'e 
10.40%;  chlorures  9.8%;  au  microscope:  globules  blancs  et  cellules  e'pithe'- 
liales  rares.  Sang:  Ure'e  0.48%. 

Antecedents:  3  avortements,  7  fils  morts  dans  les  premieres  annees  de  la 
vie. 

(6)  Aortite,  Retrecissement  Aortique.     Obs.  79  (No.  5592). 

Isabelle  C.,  60  ans,  femme.  Diagn.  ophtalm. :  0.  D.  G.,  glaucome  chronique. 
Diagn.  clinique:  Syphilis,  aortite. 

Examen  ophtalm. :  O.  D.,  cornee  de  surface  chagrinee;  pupille  mydriatique, 
immobile,  deformee;  chambre  anterieure  aplatie;  papille  vue  d  travers  un 
nuage,  est  blanchatre,  excave"e.  Vision  4/50.  Tension,  Schiotz  1/7.5  =  51 
mm.  0.  G.,  pupille  deformee,  en  mydriase  moyenne  avec  reaction  paresseuse 
£  la  lumiere,  papille  rosee,  excavee.  Vision  5/30.  Tension,  Schiotz  5/7.5 
=  26  mm. 

3  Aout:   Sciero-iridectomie  de  Lagrange  O.  D. 

13  Aout:  Tension,  O.  D.  2/7.5  =  44  mm.:  0.  G.  4/7.5  =  31  mm. 

27  Aout:  Tension,  0.  D.  1  /7.5  =  51  mm.;  0.  G.  5/7.5  =  26  mm. 

Examen  clinique:  Souffle  systolique  doux  d  1'aorte.  Pression  arterielle 
(Juillet)  Pachon,  MX.  14;  Mn.  9.5;  pression  arterielle  (1  Aout)  Pachon,  MX.  18; 
Mn.  10.5;  pression  arterielle  (27  Aout)  Pachon,  MX.  18;  Mn.  10.5.  Radio- 
scopie: Aorte  haute,  coeur  augmente  de  volume  (pointe  rejetee  de  sa  situa- 
tion normale  en  dehors).  Leger  degre  de  scierose  pulmonaire.  Reaction  de 
Wassermann :  negative ;  reactivation  de  la  reaction :  negative.  Urine :  Densite 
1026;  albumine  0.20;  beaucoup  d'indican  traces  d'urobiline;  uree  26.02%; 
chlorures  10.6%;  au  microscope:  globules  de  pus  sepals  et  en  plaques 
nombreux;  peu  de  globules  rouges  et  de  cellules  epitheiiales  renales;  rares 
cellules  vesicales;  pas  de  cylindres.  Sang:  Ur6e  0.22%. 

Antecedents:  Positifs  de  syphilis.    Veuve,  n'a  pas  eu  de  famille,  n'a  jamais 


396  CARLOS  CHARLIN 

etc"  enceinte.  Le  mari  est  mort  &  35  ans,  d'une  affection,  parait — il,  he"patique ; 
avait  la  syphilis  et  1'avait  communique'e  d  sa  femme.  Celle-ci,  au  commence- 
ment de  son  mariage,  a  souffert  de  maladies  ve'ne'riennes. 

(c)  Avec  Aortite,  Nephrite  Chronique.     Obs.  81  (No.  5630) 
The're'se  H.,  femme,  49  ans.    Diagn.  ophtalm.:    0.  D.,  glaucome  initial; 

O.  G.,  glaucome  chronique.  Diagn.  clinique  (Dr.  J.Rodriguez):  Aortite, 
nephrite  chronique,  syphilis. 

Examen  oculaire  (Juillet,  1921) :  0.  D.,  chambre  ante"rieure  un  peu  aplatie; 
pupille  en  myose  pilocarpinique;  papille  normale.  Vision  5/20.  Tension, 
Schiotz  5/7.5  =  26  mm.  0.  G.,  chambre  ante"rieure  aplatie;  pupille  en 
mydriase  moyenne  sans  reactions,  de"form6e;  papille  atrophique  avec  pro- 
fonde  excavation  glaucomateuse.  Vision,  compte  les  doigts  a  20  cm.  Tension, 
Schiotz  1  J7.5  =  52  mm. 

Examen  clinique:  Aorte  haute,  on  la  palpe,  battements  suprasternaux. 
Pression  arte'rielle  (Pachon) :  MX.  17;  Mn.  8.  Radioscopie:  Aorte  d'e"paisseur 
normale,  crossee'leve'e.  Hiles  pulmonaires  fibreux.  Reaction  deWassermann; 
negative.  Urine:  Densite1;  albumine  1.10%;  ure"e  18.21;  chlorures  11.6; 
au  microscope:  de  nombreux  globules  rouges,  peu  de  globules  blancs,  peu  de 
cellules  e'pithe'liales  polygonales ;  pas  de  cylindres.  Sang:  Ur^e  0.57%. 

Antecedents:  Syphilitiques  positifs.    Mari  syphilitique — mort  a  50  ans. 

(d)  Avec  Aortite,  Hypertension  Arterielle,  Diabete.     Obs.  91  (clien- 
t61e  particuliere). 

Juan  F.,  52  ans,  homme.  Diagn.  ophtalm.:  0.  D.,  glaucome  chronique 
ancien;  O.  G.,  glaucome  chronique  initial.  Diagn.  clinique  (Dr.  J.  Rodriguez) : 
Ancien  diabe"tique,  grande  hypertension  arte'rielle,  aortite,  syphilis  ou  tuber- 
culose  pulmonaire? 

Examen  oculaire:  A  e^e"  ope>e,  il  y  a  peu  de  mois  de  0.  D.;  depuis  quelques 
semaines  gene  a  0.  G.  0.  D.,  pupille  de'forme'e,  pyriforme,  sans  iridectomie 
pe'riphe'rique  visible;  petit  kyste  conjonctival  d  XII  en  face  de  scle'rectomie ; 
papille  blanchatre  avec  excavation  profonde  centrale.  Vision  5  /10.  Tension 
=  1,  Schiotz  9/7.5  =  14  mm.  0.  G.,  examen  ne"gatif.  Vision  5/5.  Tension 
+  1,  Schiotz  3/7.5  =  36  mm. 

Examen  clinique:  Hypertrophie  du  coeur — Dilatation  de  1'aorte  (aortite 
chronique),  renforcement  du  26me  bruit  aortique;  bruit  de  timbre  m^tallique; 
infiltration  portion  moyenne  du  poumon  gauche;  tuberculose  ou  syphilis 
pulmonaire?  Pression  arte'rielle  (Pachon):  MX.  >  35  mm.;  Mn.  9;  pouls 
110.  Radioscopie:  Aorte  grosse  et  haute-Hypertrophie  du  coeur.  Urine: 
Densite"  1019;  quantity  2800  gr.  en  24  heures.  Indices  d'albumine,  indices  de 
mucine,  glucose  25.10;  ur6e  17.40;  acide  urique  0.42;  phosphates  1.06; 
chlorures  5.60;  un  peu  d'exce's  de  leucocytes  et  quel  ques  cellules  rondes. 
Reaction  de  Wassermann  plusieurs  fois  negative  en  diff^rentes  occasions. 


L'Etat  Vasculaire  des  Glaucomateux  397 

Antecedents:  1  avortement,  4  fils  sains.  II  y  a  un  an  forte  attaque  de 
grippe,  depuis  lors,  il  dit  avoir  le  poumon  faible.  L'etiologie  de  1'affection 
pulmonaire  est  encore  en  etude. 


IV.  GLAUCOMATEUX  ARTERIOSCLEREUX 
(32  Gas) 

Nous  avons  estime  que  1'affection  vasculaire  de  nos  malades  de 
pres  de  60  ans  pouvait  e"tre  consideree  comme  obeissant  au  proces  de 
sclerose  senile,  s'il  n'existait  pas  une  autre  etiologie  capable  d'ex- 
pliquer  P  alteration  des  vaisseaux. 

Le  Glaucomateux  arteriosclereux,  non  syphilitique,  a  ete  observe 
32  fois  sur  100  malades. 

Des  100  glaucomateux  etudies,  41  avaient  plus  de  60  ans  et  de 
ceux-ci  24  etaient  arteriosclereux  et  13  syphilitiques. 

Tout  en  donnant  une  valeur  relative  d  notre  petite  statistique,  on 
pourrait  dire  que: 

Si  avant  50  ans  le  glaucomateux  est  presque  toujours  syphilitique, 
apres  les  60,  on  trouve  chez  lui  plus  sbuvent  I'arteriosclerose  que  la 
syphilis. 

Comme  chez  les  syphilitiques,  1'hypertension  arterielle  et  la  lesion 
aortique  est  d'une  grande  frequence:  Hypertension — 25  fois  sur  32 
cas;  lesion  de  1'aorte  17  fois. 

Le  retre"cissement  aortique  a  ete  trouve  2  fois. 

Le  compromis  du  rein  n'est  pas  rare,  mais  nous  repetons  ici  la  meme 
advertance  que  precedemment,  1'examen  renal  a  ete  par  trop  super- 
ficiel  dans  presque  toutes  nos  65  premieres  observations. 

Une  fois,  la  nephrite  etait  accompagnee  de  diabete  (obs.  15). 

GLAUCOMATEUX  ARTERIOSCLEREUX.  1 — (32  cas.)  (Les  observa- 
tions contenues  dans  ce  Memoire  apparaissent  soulignees.) 

(a)  Avec  signes  vasculaires  peripheriques  legers;  obs.  2,  17. 

(b)  Avec  symptomes  cardio-vasculaires  frustes;  obs.  68,  72,  74,  94' 

(c)  Avec  hypertension  arterielle;  obs.  1,  24,  64,  60,  77,  97. 

(d)  Avec  hypertension  arterielle  et  nephrite  chronique;  obs.  67. 

(e)  Avec  hypertension  arterielle  et  image  radioscopique  anormale; 
obs.  10. 

(f)  Avec  hypertension  arterielle,  image  radioscopique  anormale  et 
legere  nephrite  chronique;  obs.  68. 

1  Les  observations  de  1  a  75  forment  partie  du  Memoire  presente  £  la  Socie'te' 
d'Ophtalmologie  de  Paris. 


398  CARLOS  CHARLIN 

(g)  Avec  hypertension  arterielle  et  atherome  aortique;  obs.  5,  7, 
27,  29,  33,  35,  38,  43,  70,  85,  88. 

(h)  Avec  hypertension  arterielle  et  mitro-aortisme;  obs.  83. 

(1)    Avec  athe'rome  et  re'tre'cissement  aortique;  obs.  59. 

(m)  Avec  athe'rome  aortique,  hypertension  arte*rielle  et  nephrite 
chronique;  obs.  15,  58,  73. 

(n)  Avec  athe'rome  et  retrecissement  aortique,  hypertension  arte- 
rielle, nephrite  chronique;  obs.  61. 

II.   OBSERVATIONS  DE  GLAUCOMATEUX  ARTERIOSCLEREUX 
Contenues  dans  ce  memoire 

(a)  Avec  hypertension  arte*rielle;  obs.  60,  77,  97. 

(b)  Avec  hypertension  arte*rielle  et  mitro-aortisme;  obs.  83. 

(c)  Avec  hypertension   arterielle,    atherome    aortique,  arythmie; 
obs.  85,  88. 

(d)  Avec  symptomes  vasculaires  frustes;  obs.  94. 

(a)  Avec  Hypertension  Arterielle.  —  Obs.  60  (No.  5849). 

Cas  conside*re"  comme  negatif  dans  notre  communication  a  la  So- 
ciete"  d'Ophtalmologie  de  Paris.  La  malade  e*tant  revenue  se  pre- 
senter a  notre  clinique  au  mois  d'Aout  1921,  nous  avons  pu  constater 
alors  un  franc  compromis  du  systeme  vasculaire 


Aurora  D.,  63  ans.  Diagn.  ophtalm.  :  0.  D.  G.,  glaucome  chronique.  Diagn. 
clinique:  Cas  negatif,  Sept.  1920:  hypertension  arterielle,  nephrite  chroni- 
que hypertensive.  (Aout,  1921.) 

Examen  oculaire  (Sept.,  1920):  0.  D.,  pupille  mydriatique  avec  bonnes 
reactions,  milieux  transparents  normaux;  papille  avec  excavation  glaucoma- 
teuse  rose  clair,  halo  pe'ripapillaire.  Vision  5/7.5.  Tension  +1.  O.  G. 
Chambre  ante"rieure  trouble;  pupille  mydriatique  immobile;  papille  atrophi- 
que  avec  excavation  glaucomateuse  ;  halo  pe'ripapillaire.  Vision,  perception 
lumineuse.  Tension  +  2. 

Examen  clinique  (Sept.,  1920):  Aorte  et  coeur  normaux.  Radioscopie 
negative.  Reaction  de  Wassermann  negative.  Urine:  Ex.  ne"gatif?  (douteux). 

Examen  oculaire  (Aout,  1921):  Diagn.  ophtalm.:  O.  D.  G.,  glaucome 
absolu.  O.  D.  G.,  profonde  excavation  glaucomateuse  atrophique,  entoure"e 
d'un  halo  pe'ripapillaire;  pupilles  immobiles,  de'forme'es  en  mydriase  moyenne. 
Vision,  0.  D.  G.  =  0.  Tension.  Schiotz:  0.  D.  =  71  mm.;  0.  G.  =  60  mm. 

Examen  clinique  (Aout,  1921),  (Dr.  Borquez):  2e"me  bruit  aortique  ren- 
force".  Pression  arterielle  (Potain):  22  au  lieu  de  15  d  18;  2e"me  examen 
(Pachon):  MX.  20;  Mn.  11  (Dr.  Prado);  athe'rome  aortique.  Urine:  Densite" 


L'Etat  Vasculaire  des  Glaucomateux  399 

1017;  indices  d'urobiline;  albumine  0.20:  chlorures  7.8;  Ur^e  16.35%; 
globules  de  pus  scare's  et  en  plaques  nombreux;  quelques  globules  rouges; 
quelques  cellules  epitheiiales  polygonales  et  rondes. 

Obs.  77  (No.  5498) 

Marguerite  C.,  65  ans,  femme.  Diagn.  ophtalm.:  0.  D.  G.,  glaucome 
chronique.  Diagn.  clinique  (Dr.  Gonzalez  Cortes) :  Hypertension  arterielle. 

Examen  ophtalm.  (Juin,  1921) :  Diminution  de  la  vue  survenue  brusque- 
ment  il  y  a  plus  d'un  mois  accompagne"e  de  grandes  douleurs  frontales. 
0.  D.  G.,  injection  pe'rike'ratique,  anesthe"sie  corn^enne;  pupilles  mydriati- 
ques,  deformees,  immobiles;  fond  pas  examinable  (d  TO.  D.  on  distingue  sans 
details  la  papille).  Vision,  0.  D.  =  0;  0.  G.,  mouvements  de  la  main  a  0  m. 
50.  Tension,  0.  D.,  0.  G.  +  2. 

24  Juin:  Operation  0.  D.  sclero-iridectomie  sans  incidents. 

13  Septembre:  Tension,  Schiotz  0.  D.  8/10  23  mm.;  0.  G.  5/10  37  mm. 

Examen  clinique:  Coeur  et  aorte  ne"gatifs.  Pression  arterielle  (Pachon): 
MX.  20;  Mn.  13.  Sphygmogramme :  Tendance  au  plateau.  Radioscopie: 
negative.  Reaction  de  Wassermann  negative.  Urine:  Quantite"  2000  gr.  en 
24  heures.  Densite"  1014;  indices  d'albumine,  peu  d'  indican,  traces  d'urobi- 
line; ure"e6.50%;  chlorures  10.6%;  au  microscope;  quelques  globules  rouges; 
des  globules  blancs  et  des  cellules  epitheiiales  polygonales  rares;  pas  de 
cylindres.  Sang:  Ure"e  0.45%.  28  Septembre:  Pression  arterielle  (Pachon) : 
MX.  18;  Mn.  10.5. 

Antecedents :  Familiaux  et  personnels  sans  importance. 

Obs.  97  (No.  5772) 

Gracia  F.,  70  ans,  femme.  Diagn.  ophtalm. :  0.  D.,  glaucome  inflammatoure 
chronique;  0.  G.,  glaucome  absolu.  Diagn.  clinique  (Dr.  Rodriguez): 
Atherome  aortique — Hypertension  arterielle. 

Examen  clinique:  On  touche  1'aorte  derri^re  la  fourchette  sternale.  Pres- 
sion arterielle  (Aout)  Pachon,  MX.  17;  Mn.  12;  pression  arterielle  (13  Sept.) 
Pachon,  MX.  19;  Mn.  12.5;  pression  arterielle  (28  Sept.)  Pachon,  MX.  16;  Mn. 
9.5.  Radioscopie:  Aorte  haute,  obscure,  de  grosseur  normale.  Condensation 
peribronchiale.  Sphygmogramme  atheromateux  (plateau).  Reaction  de 
Wassermann  negative;  reactivation  negative.  Urine:  Densite"  1015;  indices 
d'albumine;  ur^e  13.01;  chlorures  6.2% ;  quelques  globules  blancs  et  cellules 
e'pithe'liales  polygonales.  Sang:  Ure"e  0.25%. 

Antecedents  personnels    Sans  importance. 

Examen  oculaire:  0.  D.,  injection  bulbaire,  chambre  anterieure  aplatie; 
pupille  en  mydriase  moyenne,  deformee,  sans  reactions,  fond  pas  examinable. 
Vision,  perception  lumineuse.  Tension  +  2,  Schiotz  >  60  mm.  0.  G., 
opacite  corneenne  legere,  pupille  mydriatique  immobile;  chambre  anterieure 
aplatie;  fond  pas  examinable.  Vision  =  0.  Tension  +  3  Schiotz  >  60mm. 


400  CARLOS  CHARLIN 

(6)  Avec  Hypertension  Arterielle  et  Mitro-aortisme. — Obs.  83  (No. 
5678). 

Rosario  A.,  64  ans,  femme.  Diagn.  ophtalm.:  O.  D.,  glaucome  inflamma- 
toire  absolu.  Diagn.  clinique  (Dr.  Borquez) :  Mitro-aortisme,  hypertension 
arte'rielle. 

Examen  oculaire  (Juillet,  1921) :  Depuis  un  mois  douleurs  oculaires  droites 
violentes  et  neVralgies  faciales.  0.  D.,  injection  bulbaire  intense;  pupille 
mj'driatique  sans  reactions;  iris  d^colore1;  corned  chagrined  avec  sensibilite" 
tre"s  diminu6e;  excavation  papillaire  glaucomateuse.  Vision  =  0.  Tension 
+  2,  Schiotz  1  /7.5  =  57  mm.  0.  G.  chambre  ante"rieure  aplatie;  papille  avec 
excavation  physiologique.  Vision  5/30.  Tension  =  1,  Schiotz  9/7.5  =  14 
mm. 

Examen  clinique:  Battements  suprasternaux  et  sous — claviers  visibles; 
coeur  augment^  de  volume,  pointe  en  dehors  de  la  ligne  mamellaire — Souffle 
systolique  mitral  et  souffle  marque",  un  peu  rude  systolique  au  foyer  aortique. 
Pression  arte'rielle  (Pachon):  MX.  21.5;  Mn.  9;  un  autre  jour  (Potain):  MX. 
20;  pouls  88.  Radioscopie:  AdheVences  costodiaphragmatiques  droites — 
Examen  aorte  et  coeur  n^gatif.  Examen  d'urine:  indices  d'albumine.  Sang: 
Uree  0.30%.  Reaction  de  Wassermann  negative. 

Antecedents  syphilitiques:  Ne*gatifs 

(c)  Avec  Hypertension  Arterielle,  Atherome  Aortique,  Arythmie.  Obs. 
85  (No.  5451). 

Manuel  G., 80  ans,  homme.  Diagn.  ophtalm.:  0.  D.  G.,  glaucome  chroni- 
que;  dacryocystite  gauche.  Diagn.  clinique  (Dr.  Rodriguez):  Atherome 
aortique,  Arythmie,  Hypertension  arte'rielle. 

Examen  oculaire  (Mai,  1921):  0.  D.  G.,  en  mydriase  moyenne  avec  fac- 
tions pupillaires  paresseuses  a  la  lumiere,  bonne  a  la  convergence;  papilles 
blanches  atrophiques  avec  excavation  pas  profonde;  champ  visuel  un  peu 
re"tr<§ci.  Vision,  0.  D.  5/15;  0.  G.  5/40.  Tension,  Schiotz  0.  D.  2/7.5  =  43 
mm.;  0.  G.  4/7.5  =  31  mm. 

Examen  clinique:  Thorax  emphysema teux;  aorte  haute,  on  la  touche 
derrie're  la  fourchette  sternale;  2e"me  bruit  aortique  renforce";  coeur  augmente" 
de  volume;  arythmie;  le  poumon  droit  ne  respire  pas  bien  a  la  base. — On 
touche  le  bord  infe'rieur  du  foie.  Pression  arte'rielle:  MX.  23;  Mn.  12.5. 
Radioscopie:  Aorte  haute  et  obscure,  coeur  tegerement  augmente"  de  volume, 
scle"rose  pulmonaire.  Reaction  de  Wassermann:  negative.  Examen  d'urine: 
Densite"  1021 ;  indices  d'albumine;  ure"e  20.19%;  chlorures  12.6%;  au  micro- 
scope: peu  de  globules  rouges  et  blancs.  Sang:  Ure"e  0.15%. 

Obs.  88  (No.  5711) 

Marie  T.,  56  ans,  femme.  Diagn.  ophtalm.:  0.  D.,  glaucome  incipient; 
O.  G.,  glaucome  absolu.  Diagn.  clinique  (Dr.  Perez  Canto):  Hypertension 
arte'rielle;  aortite,  nephrite  chronique. 


L'Etat  Vasculaire  des  Glaucomateux  401 

Examen  oculaire  (Aout,  1921):  Souffre  de  1'oeil  gauche  depuis  4  ou  5  mois 
et  dernierement  voit  moins  bien  avec  1'  0.  D.,  perception  de  cercles  colored. 
0.  D.,  chambre  anterieure  aplatie;  pupille  en  mydriase  moyenne,  avec  r^ac- 
tion  pupillaire  lumineuse  paresseuse,  reaction  de  convergence  normale. 
Examen  ophtalm. :  ne"gatif.  Vision,  O.D.  5/10.  Tension,  Schiotz  5 /7.5  =  26 
mm.  0.  G.,  corne"e  chagrine'e  avec  opacites;  chambre  anterieure  pas  aplatie, 
pupille  mydriatique  immobile;  fond  pas  examinable.  Vision  =  0.  Tension, 
Schiotz  >  1  /7.5  >  52  mm. 

Examen  clinique:  Tachycardie  (100  p.)  aorte  le'ge'rement  dilated  trans- 
versalement;  palpation  doutoureuse  des  caro tides.  Pression  arterielle 
(Pachon):  MX.  23;  Mn.  14,  d  la  radiale  gauche;  pression  arterielle  (Pachon) : 
MX.  21;  Mn.  14,  £  droite.  Radioscopie:  Aorte  haute  et  grosse;  hyper- 
trophie  du  ventricule  gauche.  Reaction  de  Wassermann  negative;  r^activa- 
tion  negative.  Examen  d'urine:  Density  1024;  albumine  0.20%;  ure"e 
15.27%;  chlorures  12.4%;  traces  d'urobiline;  au  microscope;  globules  de 
pus  se'pare's  et  en  plaques  rares;  globules  rouges  tre"s  rares;  peu  de  cellules 
epitheiiales  polygonales  et  rondes. 

Antecedents:  2  fils  sains,  pas  d'avortements  ni  de  mortus  nato. 

(d)  Avec  Symptdmes  Vasculaires  Frustes.     Obs.  94  (No.  5707). 

Toribio  P.,  68  ans,  homme.  Diagn.  ophtalm.:  O.  D.  G.,  glaucome  absolu. 
Diagn.  clinique:  Arterioscierose. 

Examen  oculaire:  0.  D.  G.,  chambres  anterieures  un  peu  efface"es;  pupilles 
deformees,  mydriatiques,  immobiles;  excavation  glaucomateuse  atrophique. 
Vision,  0.  D.  G.  =  0.  Tension,  Schiotz,  O.  D.  G.  1  /7.5  =  51  mm. 

Examen  clinique:  Bruits  valvulaires  de  ton  me"tallique.  Pression  arterielle 
(Pachon):  MX.  14.5;  Mn.  7.  Radioscopie:  Aorte  dilated  uniformement — 
Hypertrophie  du  ventricule  gauche.  Sphygmogramme  athe"romateux.  Reac- 
tion de  Wassermann  negative.  Urine:  Densite  1014;  indices  d'albumine; 
uree  8.96;  chlorures  7.8;  rares  globules  blancs  et  cellules  epitheiiales  poly- 
gonales. 

V.   GLAUCOMATEUX  AVEC  SYMPTOMES  CARDIOVASCULAIRES 
D'ETIOLOGIES  DIVERSES 

Rhumatisme — Obs.  75 
Obesite  —Obs.  69 
Douteuse  —Obs.  36,  89 

Obs.  89  (No.  5696) 

Augustin  R.,  45  ans,  homme.  Diagn.  ophtalm. :  0.  D.,  glaucome  absolu. 
Diagn.  clinique:  Nephrite  chronique  incipiente?  (Dr.  Garces.) 

Examen  oculaire:  0.  D.,  pupille  deformee,  sans  reaction  lumineuse,  papille 
atrophique  avec  excavation  glaucomateuse.    Vision  =  0.    Tension,  Schiotz 
2/7.5  =  43  mm.    0.  G.,  negatif.    Vision  5/10.    Tension  7/7.5  =  19  mm. 
26 


402  CARLOS  CHARLIN 

Examen  clinique:  Coeur  et  aorte  ne'gatif  s,  cependant  bruits  du  coeur 
e'touffe's,  systole  apre.  Pression  arte"rielle  (Pachon) :  MX.  13;  Mn.  7.  Sphyg- 
mogramme  athe'romateux  (plateau).  Radioscopie  negative.  Examen  d'urine 
ne'gatif.  Sang:  Ure'e  0.35%.  Reaction  de  Wassermann  negative;  re*activa- 
tion  negative.  Constante  d'Ambard  positive  (Dr.  Garce"s).  Ure'e  dans  le 
sang  (ur)  0.59.  Urine  produite  en  60  minutes  61  c.c. ;  urine  en  24  heures 
(selon  calcul)  1464.  Ure'e  dans  Purine  %;  (C)  17.93;  ure'e  dans  1'urine  en  24 
heur;  (D)  26,25.  Poids  du  malade;  (P)  66. 

0.59 

V70  /  17  01 

26.25  X  ^  X  V  i^  =  1.09 
DO  \       ZO 

(Normal  0.042  a  0.074.) 

VI.    GLAUCOMATEUX  A  EXAMEN  CARDIOVASCULAIRE  NEGATIF 

Ante'ce'dent  clinique:  grippe        — Obs.  44 

senilite       —Obs.  47,  65,  76,  80 
aucun        —Obs.  49 
de  syphilis— Obs.  90 

Obs.  76  (No.  5478) 

Manuel  C.,  61  ans,  homme.  Diagn.  ophtalm.:  0.  D.,  glaucome  chronique 
inflammatoire,  cataracte;  0.  G.,  glaucome  absolu.  Diagn.  clinique:  Arte'rio- 
scle'rose  se'nile  incipiente? 

Examen  ophtalm.  (28  Mai,  1921):  II  y  a  huit  ans  qu'il  ne  voit  pas  avec 
0.  G.  Depuis  quatre  ans  sa  vue  de  0.  D.  a  baisse"  progressivement.  0.  D., 
injection  pe'rike'ratique;  chambre  ant&ieure  effacee;  pupille  de'forme'e, 
mydriatique,  immobile;  opacit<3  du  cristallin.  Vision,  perception  lumineuse. 
Tension,  Schiotz  1  /10,  70  mm.  0.  G.,  injection  pe'rike'ratique  le'ge're;  cham- 
bre ant^rieure  aplatie;  pupille  mydriatique  immobile;  excavation  glaucoma- 
teuse  atrophique  profonde.  Vision  =  0.  Tension,  Schiotz  3/10,  52  mm. 

Examen  clinique :  Pouls  76,  radiale  situation  anormale,  inspection  et  palpa- 
tion negative,  renforcement  du  2e"me  bruit  aortique.  Coeur  examen  ne'gatif. 
Pression  arte"rielle  (Pachon) :  MX.  18;  Mn.  9.  Sphygmogramme  (humeral) 
trace"  suspect  d'hypertension.  Radioscopie:  Sommets  pulmonaires  obscurs; 
infiltration  fibreuse  des  poumons;  aorte  et  coeur  normaux.  Reaction  de  Wass- 
ermann negative.  Examen  d'urine:  Densite"  1017;  indices  d'albumine;  un 
peu  d'indican;  traces  d'urobiline;  ure'e  7.80%;  chlorures  8.6%;  au  micro- 
scope: globules  blancs  et  cellules  e'pithe'liales  polygonales  rares. 

Obs.  80  (No.  5587) 

Romualdo  A.,  62  ans,  homme.  Diagn.  ophtalm.:  0.  D.  G.,  glaucome 
chronique.  Diagn.  clinique:  Le'ger  degre"  d'emphyse'me  pulmonaire — Pasde 
lesions  vasculaires  perceptibles. 


L'fitat  Vasculaire  des  Glaucomateux  403 

Examen  ophtalm.:  0.  D.  G.,  chambre  ante"rieure  aplatie;  iris  normal; 
pupille  sans  reaction  lumineuse,  l^g^rement  mydriatique;  papille  blanchatre, 
excave"e.  Vision,  0.  D.,  perception  lumineuse;  0.  G.,  compte  les  doigts. 
Tension,  Schiotz  0.  D.  2/7.5  =  43  mm.;  O.  G.  3.5/7.5  =  33  mm. 

Examen  clinique:  Aorte  haute  et  e"largie?  coeur  normal.  Pression  arte"rielle 
(Pachon)  MX.  17.5,  Mn.  7.5  (on  n'a  pas  fait  de  nouvelles  me'ditionsl . 
Reaction  de  Wassermann  negative ;  (on  n'a  pas  fait  de  reactivation) .  Radio- 
scopie :  Aorte  et  coeur  normaux.  Scle"rose  pulmonaire,  le"ger  degre  d'emphy- 
se"me.  Urine:  Densite"  1025;  indices  d'albumine;  beau  coup  d'indican,  traces 
d'urobiline.  Ure"e  16.91%;  chlorures  15.2%;  au  microscope  globules  blancs 
et  rouges  rares;  peu  de  cellules  e'pithe'liales  polygonales;  pas  de  cylindres; 
de  rares  cristaux  de  phosphate  amonio-magne'sien. 

Obs.  90  (No.  4507) 

Macario  A.,homme,  62  ans.  Diagn.  ophtalm.:  0.  D.  G.,  glaucome  chroni- 
que,  avec  atrophie  papillaire.  Diagn.  clinique:  Cas  ne"gatif,  syphilis  douteuse? 

Examen  oculaire  (Novembre,  1919):  0.  D.  G.,  pupilles  en  mydriase 
moyenne  avec  bonnes  reactions ;  profonde  excavation  glaucomateuse  atrophi- 
que;  champ  visuel  retre"ci  en  dedans.  O.  D.  >  0.  G.  Vision,  O.  D.  5/30; 
0.  G.  5/10.  Tension,  0.  D.  =  1;  0.  G.  +  2.  2e"me  Examen  (Juillet,  1921). 
0.  D.  G.,  pupilles  mydriatiques  avec  reactions  pupillaires  toe's  paresseuses; 
atrophie  papillaire  avec  excavation  glaucomateuse  profonde.  Vision,  O.  D. 
mainaO.m.30;  0.  G.  5/20.  Tension,  Schiotz :  0.  D.  31mm.;  0.  G.,  37mm. 

Examen  clinique :  Cardiovasculaire  ne"gatif .  Pression  art&ielle  (Pachon) : 
MX.  18;  Mn.  7.  Radioscopie  negative.  Sphygmogramme :  Normal.  R£ac- 
tion  de  Wassermann  negative;  reactivation  negative.  Examen  d'urine: 
Ne*gatif — (ure"e  24.34,  chlorures  15.2%).  Constante  d'Ambard:  Normale 
0.056  (Dr.  Garc£s).  Reaction  de  Wassermann  chez  la  femme  negative. 

Antecedents  cliniques  de  syphilis  positifs.  Marie  2  fois — Du  premier  lit 
8  enfants,  6  vivants,  1  avortement,  1  mortus-nato — Du  2£me  lit,  le  premier 
et  le  3e"me  enfants  mortus  nato,  5  vivants. 

VII.  CONSIDERATIONS  PATHOGENIQUES — CONCLUSIONS  CLINIQUES 

Nous  venons  de  constater  que  sur  100  malades  de  glaucome  primitif 
examines  au  point  de  vue  general,  90  presentaient  des  symptomes 
vasculaires. 

On  accepte  d'autre  part  aujourd'hui  que  dans  le  glaucome  la  lesion 
anatomo-pathologique  primordiale,  et  peut-etre  initiale,  serait  la 
lesion  du  vaisseau  oculaire. 

Si  on  relationne  ces  deux  faits,  on  voit  aussitot  qu'il  doit  exister 
une  parente  tres  proche  entre  eux. 

La  clinique  en  nous  devoilant  1'hypertension  arterielle,  Faortite,  la 


404  CARLOS  CHARLON 

myocardite,  etc.,  .  .  .  sur  le  glaucomateux,  nous  oblige  d'abord  d 
accepter  au  moins  une  parent^  anatomique  entre  I'affection  oculaire 
et  I'affection  ge'ne'rale,  puisque  dans  les  deux  affections  c'est  toujours 
1'arbre  vasculaire  qui  est  malade,  que  ce  soit  dans  le  tronc  ou  dans 
ses  branches. 

La  Biologic,  de  son  c6te",  nous  dit  qu'une  lesion  vasculaire  de*ter- 
min6e  est  un  proems  toujours  le  me* me,  absolument  identique,  soit 
qu'il  se  de"roule  sur  le  vaso-vasorum  de  1'aorte,  de  Parte're  radiale 
ou  sur  les  capillaires  de  Poeil.  II  existerait  done  aussi  entre  le  proems 
vasculaire  oculaire  et  general  une  parente  pathologique. 

L'hypothe'se  qui  fait  dependre,  en  premier  lieu,  P  hypertension 
oculaire  de  la  lesion  du  vaisseau,  n'est  qu'une  hypothese,  mais  la 
frequence  extreme  du  compromis  du  systeme  vasculaire  general  chez 
le  glaucomateux,  donne  un  puissant  appui  d  cette  theorie  patho- 
ge"nique. 

Si  cette  theorie  etait  dans  le  vrai,  Petiologie  du  glaucome,  proble"me 
si  obscur,  s'e"clairerait  d'une  fac.on  inattendue. 

En  effet,  il  serait  logique  alors  d'admettre  qu'une  seule  cause  a  du 
toucher  la  paroi  vasculaire,  ici  et  Id,  le  vaso-vasorum  de  Paorte  et  le 
re"seau  ophtalmique,  malades  simultanement. 

L'examen  clinique,  Pe*tude  des  antecedents,  la  Reaction  de  Wasser- 
mann,  etc.,  .  .  .  donnent  Petiologie  de  Phypertension  arte"rielle, 
de  la  myocardite,  de  Paortite — on  arriverait  dans  le  glaucome,  par 
un  chemin  identique,  a  la  solution  du  probleme. 

En  d'autres  termes,  le  glaucome  aurait  la  mSme  signature  etiologi- 
que  que  la  cardiopathie  qui  Paccompagne. 

Mais  refusons  toute  valeur  a  ces  considerations  pathogeniques, 
comme  e"tant  de  simples  vues  de  Pesprit  non  demontrees. 

"  Le  Glaucomateux  n'est  pas  seulement  un  malade  des  des  yeux, 
puisque  dans  un  90%  des  cas  il  souffre  en  me'me  temps  d'une 
autre  affection." 

Le  me'decin  a  le  devoir  de  chercher  d  de"pister  cette  autre  maladie 
par  une  investigation  clinique  minutieuse;  Pexamen  oculaire  doit 
done  se  computer  par  Pexamen  general. 

Et  ceci  fait,  le  traitement  local  hypotensif  doit  aussi  se  computer 
par  la  therapeutique  gene"rale — propre  a  chaque  cas. — Santiago,  ler 
Decembre,  1921. 


THE  DIAGNOSIS  OF  GLAUCOMA 

COL.  R.  H.  ELLIOT 

London,  England 

To  present  a  paper  on  the  diagnosis  of  glaucoma  before  an  Inter- 
national Congress  is  a  task  entirely  different  from  that  of  writing  on 
the  same  subject  for  the  purposes  of  a  text-book,  since  a  mass  of  detail 
required  by  the  student  is  better  omitted,  attention  being  directed  to 
the  less  well-known  or  more  debatable  departments  of  the  subject. 
Another  point  to  be  borne  in  mind  is  that  diagnosis  helps  us  in  two 
somewhat  different  directions:  (1)  To  ascertain  whether  glaucoma  is 
present  or  not  and  (2)  to  enable  us  to  decide  whether  to  adopt  thera- 
peutic or  operative  measures  in  the  treatment  of  individual  cases. 

There  are  few  problems  confronting  the  ophthalmic  surgeon  which 
are  more  difficult  than  that  of  the  diagnosis  of  a  pathologic  rise  of 
tension  in  certain  cases;  and  yet  the  writer  would  desire  to  anticipate 
what  is  yet  to  come  by  the  very  emphatic  statement  of  his  belief  that 
a  surgeon,  who  will  take  the  trouble  to  avail  himself  to  the  full  of  the 
modern  methods  of  diagnosis,  need  never  be  long  in  doubt  as  to  the 
presence  or  absence  of  glaucoma.  It  is  true  that  a  correct  diagnosis 
can  sometimes  only  be  made  by  waiting ;  but  if  the  surgeon  is  alive  to 
the  condition  present,  and  loses  no  time  in  collecting  the  necessary 
data,  it  may  be  questioned  whether  the  delay  involved  need  ever  lead 
to  serious  consequences.  The  same  remarks  are  true  of  the  measures 
and  observations  necessary  to  enable  us  to  come  to  a  sure  conclusion 
as  to  whether  a  condition  of  glaucoma  is  progressive  or  stationary. 
Few  systems  are  more  evil  than  that  of  the  collective  consultation,  in 
which  a  number  of  surgeons  meet,  conduct  a  superficial  examination, 
and  assure  the  patient  that  he  should,  or  should  not,  be  operated  upon. 
Such  a  method  appeals  powerfully  to  the  patient  and  his  friends.  It  is 
popular,  dramatic,  and  worthless.  The  diagnosis  of  a  difficult  case  of 
glaucoma,  whether  the  point  at  issue  be  the  presence  of  increased  ten- 
sion or  the  question  of  the  progress  of  the  disease,  can  only  be  estab- 
lished by  the  work  of  an  individual  surgeon,  who  conducts  a  routine 
and  careful  examination,  to  which  he  is  willing  to  devote  unlimited 

405 


406  R.  H.  ELLIOT 

time.  When  all  his  data  are  available,  he  may  perhaps  with  profit  lay 
them  before  one  or  more  colleagues  and  get  the  latter  to  check  doubt- 
ful points  which  his  work  has  revealed.  This  is  not  the  method  of  the 
sensational  novelist  or  the  equally  sensational  newspaper  paragraph 
writer,  or,  only  too  often,  of  the  friends  who  prefer  the  consultation  of 
a  number  of  surgeons;  but  it  is  the  one  which  best  subserves  the  inter- 
ests of  the  patient. 

With  this  introduction,  we  shall  now  take  up  a  number  of  points  in 

turn. 

THE  CONJUNCTIVA  AND  SCLERA 

It  is  well  known  that  circumcorneal  congestion,  which  may  be  of  a 
very  pronounced  type,  is  a  constant  accompaniment  of  acute  and  sub- 
acute  glaucoma,  while  enlargement  of  the  episcleral  vessels,  and  espe- 
cially of  those  which  perforate  the  tunic  of  the  eye,  is  the  rule  in 
chronic  cases.  It  has  been  suggested  that  these  vessels  are  arteries. 
The  writer  has  no  hesitation  in  asserting  that  they  are  veins :  (1)  They 
have  the  appearance  and  color  of  veins ;  (2)  when  cut  across  in  the 
course  of  an  operation,  their  bleeding  is  typically  venous;  (3)  when 
the  lumen  of  one  of  these  vessels  is  closed  at  each  of  its  ends  as  far 
apart  as  possible,  it  not  only  fills  up  from  either  end  indifferently  when 
the  pressure  is  released,  but  it  actually  fills  from  lateral  feeder  vessels 
even  while  the  two  ends  are  still  blocked ;  (4)  under  high  magnifica- 
tion with  a  corneal  microscope  and  Gullstrand  slit-lamp,  no  pulsation 
whatever  can  be  observed  in  any  of  these  trunks. 

THE  CORNEA 

The  steaminess  of  this  membrane  in  acute  cases  and  the  secondary 
changes  in  late  cases  are  too  familiar  to  need  more  than  a  mention. 
There  are,  however,  two  symptoms  due  to  the  steaminess  of  the  cornea 
which  deserve  notice,  viz.,  mists  and  halos.  The  great  importance  of 
these  lies,  not  merely  in  the  fact  that  they  attract  the  patient's  atten- 
tion very  markedly,  but  still  more  in  that  they  serve  as  a  very  delicate 
test  of  the  recurrence  and  duration  of  exacerbations  of  the  disease. 
Those  who  are  suffering  from  simple  glaucoma,  even  with  mild  con- 
gestive intervals,  may  never  be  conscious  either  of  mists  or  of  halos, 
but  the  victims  of  acute  and  subacute  attacks  need  never  be  in  any 
doubt  as  to  the  recurrence  of  their  trouble,  once  they  have  been  trained 
to  employ  this  test. 

It  is  important  to  distinguish  two  quite  different  sets  of  conditions 
under  which  mists  and  halos  are  observed,  viz.,  (1)  in  the  early  morn- 


The  Diagnosis  of  Glaucoma  407 

ing,  and  (2)  at  those  times  of  the  day  or  night  when  fatigue  is  most 
pronounced.  The  early  morning  symptoms  are  due  to  the  failure  dur- 
ing the  sleeping  hours  of  the  pump  action,  described  by  Professor 
Thomson,  and  exerted  on  Schlemm's  canal  through  the  action  of  the 
ciliary  and  iris  muscles.  Those  which  come  on  late  in  the  day,  as  the 
result  of  fatigue,  are  to  be  attributed  to  vascular  congestion  and  are 
frequently  relieved  by  food  or  rest.  They,  in  fact,  constitute  the  in- 
cursion into  the  case  of  the  vascular  factor,  as  an  outcome  of  dis- 
turbances of  the  vasomotor  equilibrium. 

MISTS  OF  VISION. — It  is  important  to  remember  that,  though  these 
are  undoubtedly  due  in  part  to  edema  of  the  corneal  epithelium  and  of 
the  superficial  layers  of  the  cornea  (and  possibly  also  of  the  endothe- 
lium  lining1  Descemet's  membrane),  a  similar  condition  of  the  retina 
almost  certainly  plays  an  important  part  in  the  production  of  the 
symptom.  Such  a  condition  is  predisposed  to  by  the  cutting  off  in 
some  measure  of  the  arterial  blood  supply,  and  by  the  obstruction  to 
venous  return,  both  being  factors  which  interfere  with  the  due  nutri- 
tion of  the  retina. 

HALOS. — These  are  best  seen  when  looking  at  bright  lights  in  the 
dark.  When  they  are  present,  the  ordinary  patient  can  see  them  ex- 
cellently around  a  match  or  candle  flame  held  at  arm's  length.  In  the 
dark-room  the  glow  of  a  self -lit  ophthalmoscope  bulb — especially  when 
not  too  bright — gives  very  vivid  halos. 

It  is  most  important  that  our  patients  should  understand  what  we 
mean  by  halos,  since  so  many  conditions  may  easily  be  confused  with 
the  true  colored  rings  seen  by  the  glaucomatous  subject.  For  this 
purpose  a  glass  plate  dusted  with  lycopodium  should  be  kept  handy; 
once  a  patient  has  looked  through  this,  he  knows  for  all  time  exactly 
what  we  mean  when  we  ask  him  whether  he  has  seen  colored  rings. 

The  following  conditions  are  from  time  to  time  mistaken  for  halos : 
(1)  The  golden  haze  made  up  of  radiating  luminous  beams  which  a 
normal  eye  may  see  surrounding  a  light  in  the  dark,  and  which  is  often 
dissipated  by  rubbing  or  drying  the  eye.  (2)  Imaginary  halos  seen  by 
nervous  people  who  have  heard  glaucoma  discussed.  (3)  The  scintil- 
lating scotoma  of  migraine.  (4)  The  rapidly  closing  in  rings  of  color 
seen  by  nervous  or  overtired  people  when  they  shut  their  eyes  in  the 
dark.  (5)  The  halos  due  to  damage  to  the  corneal  epithelium  pro- 
duced by  caustic  and  other  medicinal  applications.  (6)  The  transient 
halos  complained  of  by  those  who  suffer  from  conjunctivitis.  These 
are  associated  with  mucous  discharge,  and  they  at  once  disappear  on 


408  R.  H.  ELLIOT 

washing  the  eye;  they  are  probably  due  to  the  inclusion  in  the  sticky 
mucus  of  masses  of  leukocytes  imprisoned  in  the  conjunctival  exudate. 
(7)  The  halos  seen  when  looking  at  a  bright  light  far  back  in  a  big 
room  through  a  steamy  plate-glass  window  from  the  dark  outside; 
these  are  the  same  as  those  seen  through  breathed  on  or  steamy  spec- 
tacle glasses.  (8)  The  halos  seen  by  some  patients  in  the  early  stage 
of  cataract;  these  are  said  to  disappear  if  looked  at  through  a  pin- 
point diaphragm.  (9)  Trie  physiologic  halos  which  any  normal  eye 
can  see  if  carefully  looked  for.  These  are  said  to  be  brighter  and  more 
prominent  in  the  old.  (10)  The  physiologic  halos  seen  by  many 
normal  eyes  when  the  pupils  are  dilated. 

The  majority  of  these  conditions  can  be  easily  differentiated  from 
the  glaucomatous  halos  by  any  surgeon  who  is  acquainted  with  the 
fact  that  they  may  possibly  be  seen  by  non-glaucomatous  people.  A 
few  inquiries  will  soon  show  their  true  nature.  There  are,  however, 
some  points  which  may  here  be  profitably  emphasized.  The  real 
glaucoma  halo  is  much  brighter  than  its  imitators;  the  patient  can 
very  easily  recognize  at  least  three  colors,  a  central  blue,  a  middle 
yellow,  and  an  outer  orange  red,  or  orange.  In  addition  a  band  of 
green  can  often  be  detected  between  the  blue  and  yellow.  The  diam- 
eter of  the  glaucomatous  halo  varies  considerably  in  different  patients, 
and  even  in  the  same  patient  at  different  times.  I  have  never  found  it 
less  than  6.50°  or  more  than  11.54°.  The  physiologic  halos,  on  the 
other  hand,  are  stated  by  authorities  to  measure  constantly  about  7° 
in  diameter.  It  has  already  been  mentioned  that  the  colored  rings  are 
very  feeble,  requiring  close  attention  for  their  recognition.  The  fact 
that  a  patient  sees  a  colored  halo  after  the  use  of  a  mydriatic  may 
easily  lead  to  the  suggestion  that  the  surgeon  has  been  guilty  of 
negligence  in  the  use  of  the  drug.  The  danger  is  all  the  greater  since 
many  members  of  the  public  are  better  informed  on  the  subject  of 
glaucoma  halos  than  the  majority  of  the  medical  profession.  It  is 
therefore  essential  that  in  every  such  case  we  should  take  note  of  the 
diameter  of  the  halos,  of  their  brilliance,  of  the  colors  recognized,  and 
of  the  tension  of  the  eye  at  the  time.  By  doing  so  we  may  save  a 
colleague  much  undeserved  discredit. 

So  important  did  this  subject  appear  to  the  writer,  that  he  sought 
the  assistance  of  Mr.  H.  H.  Emsley,  of  the  Northampton  Polytech- 
nique  Institute,  Clerkenwell.  This  gentleman  has  most  kindly  spent  a 
great  deal  of  time  and  trouble  over  the  matter.  He  points  out  that 
Druault's  test,  as  suggested  by  Morax,  is  not  quite  accurate.  If  a  true 


The  Diagnosis  of  Glaucoma  409 

glaucoma  halo,  or  any  other  halo,  due  to  interference  with  the  corneal 
tissues  is  observed,  and  at  the  same  time  a  straight-edged  screen  (a 
stenopeic  slit  held  vertically,  does  excellently)  is  moved  across  the 
area  of  vision  close  to  the  eye,  the  ring  of  the  halo  is  obliterated  just  in 
proportion  as  the  eye  is  covered  by  the  slit.  If,  on  the  contrary,  we 
observe  a  physiologic  halo — and  this  is  much  easier  with  a  dilated 
pupil — and  if  we  now  move  our  straight-edged  screen  across  the  area 
of  the  field  of  vision,  an  entirely  different  phenomenon  is  seen,  due  to 
the  fact  that  the  halo  is  here  produced  by  the  grid-like  criss-crossing 
of  the  lens  fibers.  As  the  screen  comes  across  the  eye,  instead  of  seeing 
the  complete  halo,  we  now  only  see  two  rather  narrow  spectral  bands, 
one  at  each  end  of  a  diameter  of  the  halo ;  with  the  movement  of  the 
screen,  these  swing  round  like  the  spokes  of  a  cart-wheel,  traveling 
clockwise  or  counter-clockwise  alternately,  according  as  the  screen  is 
moved  in  one  or  the  other  direction.  This  beautiful  little  experiment 
of  Mr.  Emsley's  enables  us  to  tell  at  once  whether  the  halos — whether 
seen  spontaneously  by  the  old,  or  as  a  result  of  mydriasis  in  younger 
people — are  produced  by  the  lens  fibers,  or  are  truly  corneal.  In  the 
former  case  they  have  no  connection  with  the  intraocular  pressure; 
in  the  latter,  they  may  or  may  not  have  such  a  connection. 

A  last  word  as  to  the  measurements  of  halos:  With  the  light  10  feet 
from  the  observing  eye,  the  diameters  of  the  halos  will  be  approxi- 
mately as  follows:  For  4°,  8.5  inches;  for  5°,  10.5  inches;  for  6°,  12.5 
inches;  for  7°,  14.75  inches;  for  8°,  17  inches;  for  9°,  19  inches;  for 

10°,  21  inches;  for  11°,  23.33  inches;  for  12°,  25.35  inches. 

« 

THE  ANTERIOR  CHAMBER 

SHALLOWING  OF  THE  ANTERIOR  CHAMBER. — This  well-known  sign 
may  occur  under  two  quite  different  conditions:  (1)  It  may  be  the 
result  of  an  overdistention  of  the  vitreous  body,  of  congestion  of  the 
ciliary  body,  or  of  both ;  or  (2)  it  may  result  from  the  sealing  down  of 
the  angle  of  the  chamber,  due  to  the  adhesion  of  the  iris  base  to  the 
corneal  periphery. 

In  either  case,  and  especially  in  the  latter,  it  may  be  important  to 
be  able  to  measure  the  depth  of  the  chamber.  Much  information  may 
thus,  possibly,  be  obtained  as  to  the  progress  a  case  is  making  on  the 
downward  road,  and  as  to  the  prospect  of  an  operation  proving  a 
success.  With  regard  to  the  latter  point,  the  writer  holds  strongly 
that  an  iridectomy  is  useless  once  the  angle  is  sealed  down,  unless  it 
accidentally  gives  rise  to  a  filtering  scar.  If  this  be  accepted,  it  is 


410  R.  H.  ELLIOT 

obvious  that  we  should  aim  at  performing  a  filtering  operation  to 
start  with,  and  should  not  leave  our  main  object  to  be  the  sport  of 
chance.  Again,  if  we  desire  to  trephine,  it  is  of  importance  to  know 
beforehand  how  far  forward  the  obliteration  of  the  angle  has  pro- 
gressed, and,  if  we  have  reason  to  believe  that  it  is  very  far  forward, 
we  should  get  all  the  corneal  splitting  we  safely  can. 

Messrs.  Zeiss  have  fitted  to  their  corneal  microscope  a  device  known 
as  "the  Ulbrich  drum."  With  the  aid  of  this,  and  by  a  simple  cal- 
culation, the  depth  of  the  chamber  can  easily  be  measured.  Even 
apart  from  any  calculation,  the  relative  depths  of  the  same  chamber 
can  be  estimated  from  time  to  time;  this  is  probably  the  most  impor- 
tant element  in  the  case. 

These  considerations  have  been  put  forward  because  it  seems  prob- 
able that  important  advances  can  be  made  if  such  lines  of  work  are 
followed  up;  and  America  is  far  more  likely  to  do  the  work  than  most 
parts  of  Europe,  for  the  present  at  least. 

CLOUDINESS  OF  THE  ANTERIOR  CHAMBER,  OR  THE  PRESENCE  OF 
DEPOSITS  ON  THE  ANTERIOR  SURFACE  OF  THE  IRIS,  OR  ON  THE  POS- 
TERIOR SURFACE  OF  THE  CORNEA. — These  are,  in  reality,  signs  of  an 
iridocyclitis;  their  observation  is  most  important,  as  the  diagnosis  of 
the  cause  of  the  glaucoma,  and  the  main  indication  for  the  exhibition 
of  mydriatic  drugs  hang  on  their  recognition.  This  point  was  well 
brought  out  in  the  valuable  discussion  before  the  American  Ophthal- 
mological  Society,  at  their  Fifty-fifth  Annual  Meeting  in  Atlantic 
City  in  1919. 

KOEPPE'S  SIGN. — Koeppe  has  claimed  that  glaucoma  can  be  rec- 
ognized, even  in  what  he  terms  "the  pre-glaucomatous  stage,"  by  the 
aid  of  the  Gullstrand  slit-lamp — and  this  months  or  even  a  year  be- 
fore any  other  sign  of  the  disease  has  appeared.  He  states  that  as.  a 
result  of  the  morbid  changes,  which  are  taking  place,  pigment  granules 
are  set  free,  and  that  these  wander  out  in  the  form  of  a  fine  dust,  and 
are  to  be  seen  on  the  surface  of  the  iris  stroma.  The  observation  has 
been  both  supported  and  contradicted.  The  writer  has  certainly  seen 
such  granules  in  glaucoma  cases,  but,  he  has  also  seen  unquestioned 
cases  of  established  glaucoma,  in  which  no  trace  of  them  can  be  de- 
tected. The  matter  is  one  of  great  interest,  and  as  some  American 
ophthalmologists  have  devoted  their  attention  to  the  subject,  it  is  to 
be  sincerely  hoped  that  some  further  light  will  be  shed  on  it  at  the 
Congress.  If  we  could,  by  this  or  by  any  other  means,  anticipate  a 
certain  diagnosis  of  progressive  glaucoma,  it  would  be  of  incalculable 


The  Diagnosis  of  Glaucoma  411 

benefit  to  us,  for  we  could  then  undertake  a  well-planned  operation  at 
a  date  when  everything  is  in  favor  of  success,  instead  of  being  forced  to 
resort  to  surgery  at  a  dangerous  time,  as  is  now  only  too  often  the 
case. 

THE  CILIARY  BODY 

The  impairment  of  accommodation  which  accompanies  glaucoma 
is  too  well  known  to  require  more  than  a  passing  mention.  The  ap- 
pearance of  a  manifest  hyperopia  is  less  widely  recognized  as  a  sign  of 
the  disease,  although  it  is  far  from  being  uncommon.  Its  genesis  is 
easily  explained:  The  original  condition  in  such  cases  was  one  of 
latent  hyperopia;  under  the  paralyzing  influence  of  the  increase  of 
pressure,  acting  upon  the  third  nerves  and  on  their  terminals  in  the 
ciliary  muscles,  the  hyperopia  has  become  manifest. 

THE  LENS 

Much  has  been  written  recently  on  the  subject  of  cataract  com- 
plicating glaucoma.  It  is  necessary  to  distinguish  sharply  between 
3  conditions  which  are  too  often  confused  with  each  other: 

(1)  The  form  of  cataract  secondary  to  glaucoma  is  characterized  by  a 
want  of  definition  in  its  appearance.    It  looks  like  a  smoky,  greenish 
or  bluish  haze,  and  does  not  present  the  definite  features  with  which 
we  are  all  familiar  in  an  ordinary  primary  cataract. 

(2)  Glaucoma  Secondary  to  Cataract. — The  appearance  of  the  lens  in 
the  majority  of  these  cases  is  characteristic  of  the  intumescent  variety, 
the  history  is  unmistakable,  and  the  presence  of  a  primary  and  hith- 
erto uncomplicated  cataract  in  the  opposite  eye  clinches  the  diagnosis. 

(3)  Cataract  occurring  as  an  accidental  complication  of  glaucoma  is 
by  no  means  uncommonly  met  with  by  any  surgeon  in  large  practice. 

The  so-called  "green  reflex  of  glaucoma"  is  not  characteristic  of  the 
disease;  it  can  be  often  seen  in  old  eyes;  the  conditions  that  favor  its 
appearance  are  a  dilatation  of  the  pupil  combined  with  some  want  of 
perfect  transparence  of  the  aqueous  humor,  lens,  and  cornea,  or  of  all 
three  combined. 

THE  OPTIC  Disc  AND  RETINA 

CUPPING  OF  THE  OPTIC  Disc. — The  typical  cupping  of  the  optic 
disc,  on  which  so  much  reliance  is  placed,  is  a  feature  of  established 
glaucoma,  and  is  often  absent  in  early  cases.  The  sign  may,  therefore, 
fail  us  in  the  very  class  of  case  in  which  the  greatest  difficulty  in 
diagnosis  occurs. 


412  R.  H.  ELLIOT 

The  method  of  formation  of  the  cup  in  the  great  majority  of  cases  is 
typical  and  unmistakable:  (1)  If  a  case  is  watched  from  the  first,  a 
slight  and  subtle  change  is  observed  at  the  very  margin  of  the  disc; 
this,  either  around  a  large  area  or  throughout  the  whole  circumference, 
shows  a  slight  depression,  not  sufficient  to  be  estimated  by  the  aid  of 
the  ophthalmoscope  but  quite  enough  to  be  recognized  by  any  trained 
observer.  (2)  At  a  slightly  later  stage  a  faint  bend  can  be  observed  in 
the  course  of  the  vessels  as  they  pass  over  this  depressed  margin;  by 
this  time  the  whole  circumference  of  the  disc  tends  to  be  involved. 
(3)  As  time  goes  on,  the  depression  in  the  floor  of  the  disc  increases  so 
that  it  can  be  estimated  ophthalmoscopically,  and  the  kinking  of  the 
emerging  vessels  becomes  increasingly  accentuated. 

The  aberrant  types  of  cupping  are  comparatively  rarely  met  with. 
This  is  all  the  stronger  reason  for  the  surgeon  to  be  on  his  guard  and 
prepared  to  recognize  them  early.  They  are  of  two  types:  (1)  The 
circular,  central,  physiologic  cup,  which  gradually  widens  out  toward 
the  circumference  on  the  papilla,  and  (2)  the  steadily  enlarging  physio- 
logic cup.  It  is  necessary  to  repeat  that  these  are  rare  forms  of  cup- 
ping, and  that  the  diagnosis  of  glaucoma  in  such  cases  must  rest  on  a 
comprehensive  survey  of  all  the  evidence  that  the  case  can  afford. 

PULSATION  OF  THE  RETINAL  VESSELS. — We  must  take  the  veins 
and  arteries  separately: 

THE  RETINAL  VEINS. — It  is  commonly  believed  that  retinal  venous 
pulsation  is  a  sign  of  glaucoma.  This  view  has  recently  been  chal- 
lenged, and  the  writer  has  therefore  studied  the  subject  very  closely. 
There  can  be  no  question  that  venous  pulsation — and  even  strong 
venous  pulsation — may  be  met  with  in  eyes  in  which  the  tension  is 
normal,  and,  again,  that  a  complete  absence  of  pulsation  may  be  found 
in  high  tension  eyes.  There  are,  however,  certain  items  of  evidence 
which  we  must  consider:  (1)  The  exertion  of  a  moderate  amount  of 
digital  pressure  on  the  globe  will  in  many  cases  provoke  a  marked 
venous  pulsation  or  exaggerate  a  pulsation  already  present.  (2)  The 
instillation  of  mydriatic  drugs  into  the  eye  will,  in  a  certain  number  of 
cases,  have  a  precisely  similar  effect.  (3)  In  a  number  of  cases  of 
glaucoma  a  very  marked  venous  pulsation  will  be  found  present,  and 
in  not  a  few  of  these  this  pulsation  will  disappear  or  greatly  lessen  in 
character  after  the  performance  of  a  successful  decompression  opera- 
tion. The  writer's  view  is  that  when  the  other  features  of  a  case  point 
toward  glaucoma,  the  presence  of  a  marked  venous  pulsation  in  the 
retina  is  a  suggestive  piece  of  contributory  evidence.  Further,  the 


The  Diagnosis  of  Glaucoma  413 

presence  of  such  a  marked  venous  pulsation,  whenever  it  is  detected, 
should  raise  in  the  observer's  mind  the  possibility  of  a  threatening  of 
glaucoma.  The  circulation  within  the  eye  has  a  marvelous  power  of 
adapting  itself  to  altered  conditions,  but  in  the  transition  stage  from 
one  condition  to  another,  the  vascular  system  may  give  such  evidence 
as  we  have  been  discussing  of  the  strain  which  is  being  put  upon  it. 
THE  RETINAL  ARTERIES. — Spontaneous  pulsation  of  the  retinal 
arteries  is  spoken  of  in  the  text-books  as  though  it  were  a  common,  if 
not  an  invariable,  accompaniment  of  glaucoma,  whereas  the  truth  is 
that  it  is  a  sign  which  is  very  rarely  seen  indeed,  and  then  only  in  the 
course  of  congestive  attacks  of  the  disease,  passing  away  as  soon  as 
the  exacerbation  is  got  under  control.  The  writer  can  never  recall  a 
single  instance  in  which  he  has  detected  it  in  an  eye  suffering  from  sim- 
ple glaucoma  or  in  a  congestive  case  in  the  interval  between  two  at- 
tacks. In  many  of  our  cases  of  acute  glaucoma — and  by  this  we 
mean  acute  exacerbations  of  a  glaucomatous  condition — the  media  are 
too  hazy  to  allow  us  to  see  pulsation  of  the  retinal  vessels.  In  others 
we  can  see  the  vessels  and  note  the  absence  of  pulsation,  while  in  yet 
others — and  these  very  few  in  number — a  distinct,  and  sometimes  a 
very  marked,  arterial  pulsation  may  be  clearly  discerned.  We  know 
that  arterial  pulsation  means  an  intermittence  of  the  even  flow  of 
blood  through  the  arteries,  as  a  result  of  the  intraocular  pressure  hav- 
ing risen  to  such  a  height  that  it  is  greater  than  the  retinal  arterial 
pressure  during  the  diastolic  phase  of  the  latter.  In  other  words,  it  is 
clear  evidence  that  the  retinal  circulation  has  become  intermittent 
instead  of  continuous.  Very  different  grades  of  this  condition  can  be 
recognized:  (1)  The  arterial  pulse  is  nothing  more  than  a  flicker 
which  affects,  however,  the  whole  course  of  every  branch  of  the  retinal 
artery  on  the  disc  and  even  beyond  it;  it  can  be  counted  against,  and 
confirmed  by  the  radial  pulse.  Here  we  obviously  have  to  do  with  the 
slightest  possible  interference  with  the  retinal  arterial  circulation;  it  is 
only  at  the  lowest  phase  of  diastole  that  the  even  flow  of  the  current 
is  interrupted.  (2)  The  arterial  pulse  becomes  more  and  more  marked; 
the  phase  of  blanching  of  the  artery  may  be  so  prolonged  as  to  equal  or 
exceed  that  of  its  greatest  fulness  with  blood;  here  the  interruption  of 
the  retinal  circulation  is  obviously  becoming  very  serious.  (3)  In 
extreme  cases  the  intraocular  pressure  has  become  so  excessive  that 
circulation  can  only  be  maintained  at  the  height  of  systolic  pressure ; 
the  phases  of  blanching  of  the  vessels  exceed  those  in  which  they  are 
filled,  giving  almost  the  appearance  of  an  aortic  pulse,  and  justifying 


414  R.  H.  ELLIOT 

the  simile,  used  by  a  French  writer,  that  the  blood  seems  to  spill  in 
jets  over  the  edge  of  the  disc. 

It  will  require  but  little  consideration  to  show  any  thoughtful  mind 
that  the  watching  of  this  phenomenon  will  provide  valuable  clinical 
data  to  the  observant  ophthalmologist.  So  far  we  have  been  dis- 
cussing the  spontaneous  arterial  retinal  pulse.  We  shall  now  turn  to 
consider  a  phenomenon  which  can  be  observed  not  only  in  glaucoma- 
tous,  but  also  in  healthy  eyes,  and  yet  one  which  has  a  very  definite 
clinical  significance. 

The  Induced  Pulsation  of  the  Retinal  Arteries. — It  is  well  known  that  by 
the  exertion  of  digital  pressure  on  the  globe  of  the  eye  we  can  produce 
a  pulse  in  the  retinal  arteries.  This  pulse  follows  closely  the  char- 
acters described  in  dealing  with  the  spontaneous  arterial  pulse :  With 
mild  pressure  the  phase  of  interruption  is  extremely  short.  As  the 
pressure  is  increased  it  lengthens  until  it  exceeds  the  period  of  onward 
flow.  Finally,  if  the  pressure  is  made  still  greater — and  it  is  question- 
able whether  we  have  a  right  to  employ  such  a  means — the  whole 
circulation  through  the  eye  is  stopped,  and  the  current  through  the 
retinal  arteries  definitely  ceases. 

The  real  value  of  these  observations  lies  in  the  fact  that,  as  the  intra- 
ocular pressure  rises,  the  amount  of  digital  pressure  necessary  to  pro- 
duce a  retinal  arterial  pulse  tends  to  become  less  and  less;  conse- 
quently, when  we  can  evoke  an  arterial  pulse  by  light  pressure  upon 
the  eye  we  are  led  to  the  conclusion  that  the  intraocular  pressure  has 
risen  until  it  is  nearly  equal  to  the  diastolic  arterial  pressure.  The 
word  "tends"  has  been  advisedly  and  deliberately  used,  and  for  the 
following  reason:  There  are  cases  of  undoubted  glaucoma  in  which 
quite  considerable  pressure  is  required  before  the  arterial  pulse  can  be 
elicited,  and  there  are  cases  in  which  no  rise  whatever  of  intraocular 
pressure  has  taken  place,  in  which  the  diastolic  pulse  can  be  very  easily 
produced  by  light  pressure;  this  latter  occurrence  is  most  often  met 
with  in  young  eyes.  It  is  obvious  that  in  the  former  class  of  cases, 
the  arterial  pressure  has  risen  part  passu  with  the  rise  in  intraocular 
pressure — one  more  instance  of  the  compensatory  mechanism  which 
is  to  be  found  in  the  eye,  and  whose  working  we  understand  so  little. 
In  the  latter  class  we  appear  to  have  to  do  with  a  condition  in  which 
the  normal  diastolic  arterial  pressure  is  unusually  low. 

PALLOR  OF  THE  Disc. — This  pallor  may  be  found  under  two  quite 
different  conditions :  (1)  It  is  seen  in  some  cases  of  glaucoma  at  a  very 
early  stage,  and  is  then  presumably  due  to  a  constriction  of  the 


The  Diagnosis  of  Glaucoma  415 

vascular  supply  as  a  result  of  increased  ocular  pressure.  That  this 
should  be  so  will  surprise  no  one  who  is  familiar  with  the  very  marked 
blanching  of  the  disc  which  is  produced  by  digital  pressure.  It  has 
been  claimed  that  it  may  be  a  very  early  and  very  suggestive  sign,  in 
the  absence  of  other  evidence,  of  an  increase  in  intraocular  pressure. 
This  is  certainly  a  point  which  should  be  kept  carefully  in  mind,  for  in 
no  disease  is  it  truer  that  every  shred  of  evidence  helps.  (2)  It  is  met 
with  as  a  marked,  and  often  as  an  unmistakable,  feature  of  estab- 
lished glaucoma.  Its  interest  here  lies  not  so  much  in  establishing  the 
diagnosis  of  the  disease — which  by  this  time  has  usually  already  been 
made  without  difficulty — but  in  furnishing  a  criterion  as  to  the  prob- 
able prognosis  for  vision,  if  and  after  a  successful  decompression  opera- 
tion has  been  performed.  A  similar  relative  pallor  of  the  retina  may 
sometimes  be  observed.  This  is,  however,  very  difficult  to  appreciate, 
and  a  more  significant  sign  is  therefore  to  be  found  in  a  slight  relative 
decrease  of  the  diameters  of  the  arteries,  as  compared  with  those  of 
the  veins. 

A  dragging  over  of  the  retinal  vessels  in  a  bundle  toward  the  nasal 
side  of  the  fundus  is  a  not  uncommon  phenomenon  in  late  cases  of 
glaucoma,  and  the  appearance  presented  is  very  striking.  Even  when 
there  are  considerable  opacities  in  the  media  of  the  eye,  the  bundle  of 
red  lines  running  inward  and  the  contrasting  dead  whiteness  of  the 
disc  in  every  other  direction  furnish  a  picture  which  is  unmistakable. 
This  dragging  over  of  the  vessels  is  probably  always  associated  with 
some  measure  of  posterior  staphyloma. 

THE  SIZE  OF  THE  GLOBE 

According  to  Priestley  Smith,  the  average  horizontal  diameter  of 
the  cornea  is  11.1  mm.  in  the  glaucoma tous  as  against  11.6  mm.  in 
healthy  eyes.  The  importance  of  this  fact  lies  in  the  help  it  gives  us, 
when  patients  with  a  glaucomatous  family  history  consult  us  as  to 
the  condition  of  their  own  eyes,  being  made  nervous  by  the  fear  that 
they  may  have  inherited  the  disease.  Should  we  find  that  they  have  a 
low  corneal  diameter  we  would  be  justified  in  recommending  them  to 
keep  themselves  under  periodic  observation,  and  to  report  the  ap- 
pearance of  any  suspicious  symptoms  of  the  disease.  On  the  other 
hand,  the  observation  of  a  large  corneal  diameter  would  be  a  distinct 
factor  in  enabling  us  to  give  a  good  prognosis.  The  writer  has  been 
extremely  dissatisfied  with  the  devices  employed  for  making  these 
measurements;  they  seem  to  him  far  too  rough  and  ready  for  their 


416  R.  H.  ELLIOT 

purpose.  If  it  is  important  to  have  the  information,  that  information 
should  be  as  exact  as  it  is  possible  to  make  it.  This  is  the  principle  on 
which  all  our  examinations  of  the  glaucoma  patient  should  be  con- 
ducted if  the  opinions  we  give  are  to  be  really  reliable.  The 
requisites  for  a  perfect  instrument  of  the  kind  are:  (1)  A  head-rest 
must  be  provided,  so  that  the  patient  may  be  absolutely  steady. 
(2)  The  instrument  itself  must  be  rigidly  fixed  on  a  firm  stand.  (3) 
The  observed  eye  must  have  a  definite  point  of  fixation,  so  that  it  may 
not  make  the  least  move  during  the  examination.  (4)  The  scale  and 
the  eye  must  be  sufficiently  magnified  to  enable  the  observer  to 
measure  accurately  in  tenths  and  preferably  in  twentieths  of  a  milli- 
meter. Messrs.  Zeiss  are  constructing  such  an  instrument  especially 
for  the  writer,  which  will  give  a  magnification  of  eight  diameters.  This 
can  be  substituted  for  their  corneal  microscope  on  the  standard  adjust- 
ment stand  of  that  instrument,  and  will  be  focused  by  a  rack  and 
pinion  movement. 

SUBJECTIVE  PHENOMENA 

PAIN. — Speaking  broadly,  pain  is  here,  as  elsewhere,  a  measure  of 
the  congestion  present.  A  simple  glaucoma  may  run  its  whole  course 
without  one  moment  of  pain  in  the  eye.  Again,  the  early  slight  at- 
tacks of  subacute  glaucoma  may  be  attended  only  by  mild  feelings  of 
discmofort  or  of  ocular  pressure.  On  the  other  hand,  the  acute  dis- 
ease is  marked  by  great  suffering.  Our  principal  interest  in  the  subject 
lies  in  the  fact  that  the  trouble  is  not  always  referred  to  the  eye ;  the 
patient  and  even  his  medical  adviser  may  make  the  mistake  of  think- 
ing that  the  cause  of  the  trouble  is  in  the  teeth,  the  ears,  or  the  nose, 
since  the  'neuralgia"  complained  of  appears  to  start  from  one  of 
those  organs.  Again,  as  we  well  know,  the  headache,  vomiting,  and 
pyrexia  may  lead  to  the  erroneous  and  mischievous  diagnosis  of  that 
refuge  of  incompetence,  "  the  bilious  headache."  The  taking  of  a  meal 
or  the  obtaining  of  sleep  may  greatly  alleviate  the  symptoms;  such 
drugs  as  phenacetin  and  antipyrin  are  useless,  while  the  bold  instilla- 
tion of  miotics  acts  like  a  charm.  All  these  are  points  that  help  the 
careful  surgeon  to  a  right  appreciation  of  the  cause  of  a  patient's 
suffering. 

LACRIMATION. — According  to  Morax,  various  reflex  troubles  may 
suggest  the  commencement  of  glaucoma;  the  most  suspicious  of  these 
is  intermittent  lacrimation,  unconnected  with  wind  or  other  pro- 
vocative agency. 


The  Diagnosis  of  Glaucoma  417 

NAUSEA  AND  VOMITING. — Morax  states  that,  even  if  the  glaucoma 
is  untreated,  the  actual  vomiting  subsides  within  twenty-four  or  at 
most  forty-eight  hours,  while  the  sensation  of  nausea  may  persist  for 
several  weeks.  He  has  met  with  patients  suffering  from  subacute 
attacks,  in  whom  the  feeling  of  nausea  was  the  only  warning  sign  of  a 
fresh  rise  in  intraocular  pressure. 

PHOTOPSI^E  are  not  unknown  in  the  early  stages  of  congestive 
glaucoma.  They  may  occur  as  flashes  of  light,  as  the  impression  of  a 
ball  of  fire  which  rolls  across  the  field  of  vision,  as  sudden,  sharp, 
flash-like  spots  of  light,  or  as  a  continuous  luminous  glow,  lasting 
from  seconds  to  minutes  or  even  longer.  The  patient  is  most  apt  to 
suffer  from  these  photopsise  when  he  is  tired  and  when  he  first  gets  into 
bed  at  night.  It  must  be  remembered  that  like  symptoms  may  be 
observed  under  any  conditions  in  which  the  retina  is  irritated,  dragged 
upon,  or  otherwise  interfered  with.  Nor  must  we  forget  that  similar 
phenomena,  but  of  central  origin,  are  met  with  in  neurasthenic  pa- 
tients suffering  from  errors  of  refraction,  from  migraine,  and  from  other 
nervous  troubles.  Rest  tends  to  relieve  photopsise  of  retinal  origin, 
while  those  due  to  cerebral  trouble  are  often  worst  at  night. 

RAINBOWS  ROUND  LIGHTS. — These  have  already  been  discussed. 

A  DIMINUTION  OF  VISUAL  ACUITY  is  a  frequent,  if  not  a  constant, 
sign  of  glaucoma;  its  causes  may  be  classified  into  (1)  medial  and  (2) 
neuroretinal.  The  former  include  (a)  interference  with  the  refractile 
power  of  the  cornea,  owing  to  overstretching  of  that  membrane;  (b) 
corneal  edema;  (c)  deposits  on  the  back  of  the  cornea;  (d)  degenera- 
tive and  other  permanent  changes  in  the  cornea;  (e)  turbidity  of  the 
aqueous;  (f)  opacities  in  the  lens;  (g)  deposits  of  various  kinds  on  the 
surface  of  the  lens  capsule;  and  (h)  vitreous  opacities.  (2)  Neuro- 
retinal causes  include  pressure  on,  and  overstretching  of,  the  bundles 
of  the  optic  nerve  and  of  the  layers  of  the  retina  and  (b)  starvation  of 
the  nerve  and  retina  due  to  interference  with  the  blood  supply  as  a 
result  of  intraocular  pressure.  The  lesion  may  be  manifested  by  a 
diminution  of  central  vision  or  by  an  interference  with  the  visual  field. 
The  former  is  practically  always  an  evidence  that  a  congestive  element 
has  entered  into  the  case;  otherwise  good  central  vision  is  retained 
almost  to  the  last.  Defects  in  the  field,  on  the  other  hand,  are  to  be 
attributed  to  injury  to  the  nerve  fibers  at  the  edge  of  the  disc,  rein- 
forced by  starvation  of  the  retinal  blood  supply.  The  distinction  is 
obviously  important. 

27 


418  R.  H.  ELLIOT 

THE  VISUAL  FIELD 

The  subject  of  the  changes  in  the  visual  field  in  glaucoma  is  so  vast 
that  it  will  be  possible  only  to  touch  on  a  few  of  the  main  points  of 
interest.  The  examination  of  a  suspected  glaucoma  patient  is  very 
incomplete  unless  the  fields  have  been  carefully  taken.  Nor  does  one 
measurement  suffice  for  each  eye.  The  whole  field  should  first  be 
charted  on  a  short  radius  (33  cm.)  instrument,  care  being  taken  that 
the  moving  object  is  sufficiently  small  (not  above  3  mm.  in  diameter 
for  a  daylight  instrument) ;  next,  the  central  portion  of  the  field,  lying 
within  26°  of  the  center,  should  be  examined  at  a  distance  of  1  m.  with 
a  1  mm.  object.  The  results  obtained  by  the  two  procedures  are  best 
kept  on  separate  charts. 

PERIMETRY  OF  THE  WHOLE  FIELD. — From  this  method  we  obtain 
certain  very  important  indications:  (1)  There  is  a  tendency  for  the 
nasal  portion  of  the  field  to  be  affected  before  the  temporal,  and  also 
for  it  to  be  more  affected  than  the  temporal,  as  the  disease  runs  its 
course.  Though  this  is  not  an  invariable  rule,  it  is  so  frequent  an 
occurrence  that  it  deserves  to  be  kept  carefully  in  mind.  (2)  As  the 
disease  progresses,  the  whole  field  tends  to  shrink  from  the  periphery 
toward  the  center.  (3)  The  blind  spot  shows  distinct  signs  of  enlarge- 
ment, even  on  examination  by  the  small  perimeter,  if  the  fields  are 
carefully  taken  from  time  to  time  as  the  disease  progresses.  (4) 
Roenne's  step  appears  on  the  charts  (Fig.  1).  This  has  been  de- 
liberately left  till  the  last,  not  because  it  is  the  least  important  but 
because  the  writer  desires  to  draw  special  attention  to  it.  This  sign 
is  far  too  little  known  and  appreciated.  It  is  an  evidence  of  the  lesion 
of  the  optic  nerve  bundles  at  the  edge  of  the  disc  (Fig,  2),  and  it 
therefore  clearly  points  to  the  essential  pathologic  process  which  is 
responsible  for  the  harm  done  to  the  optic  nerve  as  a  result  of  in- 
creased pressure  within  the  eye.  This  does  not  mean  that  it  is 
necessarily  pathognomonic  of  glaucoma,  for  we  know  that  other  mor- 
bid conditions  may  damage  the  nerve  fibers  as  the  latter  flow  over  the 
edge  of  the  disc.  Nor,  again,  does  it  imply  any  doubt  as  to  the  influ- 
ence of  the  vascular  factor  in  the  damage  inflicted  on  the  optic  nerve 
and  retina.  It  is  obvious  that  the  nerve  fibers  and  retinal  elements, 
which  are  starved  of  arterial  blood  and  engorged  with  venous  blood, 
as  a  result  of  increased  pressure  within  the  eye,  must  be  thereby 
placed  in  a  condition  unfavorable  to  the  resistance  of  trauma.  In  this 
we  see  the  contributory  element  furnished  by  interference  with  the 


The  Diagnosis  of  Glaucoma 


419 


Fig.  1. — Chart  from  R.  E.  with  chronic  glaucoma.  Bjerrum's  sign  is  well 
shown.  So  also  is  Roenne's  sign.  The  most  severe  lesions  to  the  bundles  of  optic 
nerve- fibers  lie  at  the  upper  temporal  edge  of  the  disc;  compare  with  diagram  in 
Fig.  2.  Over  the  dotted  area  vision  is  indistinct. 


•POR.M- 


Fig.  2. — The  diagram  shows  roughly  the  defects  in  the  nerve  bundles  of  the 
retina,  which  would  correspond  with  the  visual  field  defects  shown  in  Fig.  1.  The 
illustration  is  diagrammatic  and  only  approximate. 


420  R.  H.  ELLIOT 

retinal  and  choroidal  vascular  blood  supply;  but  it  cannot  be  too 
strongly  emphasized  that  for  the  essential  lesions  of  glaucoma,  and 
for  the  evidence  whereby  we  diagnose  them  by  means  of  perimetry 
we  must  look  to  the  edge  of  the  disc  and  to  the  damage  done  to  the 
nerve  fibers  at  that  area.  This  being  so,  the  importance  of  Roenne's 
sign  stands  out  large  against  the  background  of  other  perimetric  ob- 
servations. Why  has  it  been  so  little  appreciated,  and  why  is  it  so 
seldom  observed?  The  answer  is :  Because  so  much  of  the  perimetric 
work  in  consulting  rooms  and  other  places  is  done  against  time,  and 
sufficient  leisure  and  trouble  is  not  devoted  to  it.  Moreover,  as  has  so 
often  been  pointed  out,  this  sign  is  best  observed  when  the  circular 
method  of  perimetry  is  adopted,  for  the  simple  reason  that  the  fibers, 
whose  damage  we  are  studying,  run  in  arc-like  curves  around  the  cen- 
ter of  vision,  and  any  lesions  they  sustain  are  more  easily  studied  when 
the  observed  object  travels  along  the  length  of  the  fibers  instead  of 
across  them.  To  take  eight  radial  measurements  of  a  field,  and  then  to 
fill  in  a  chart  by  drawing  lines  between  them  is  not  perimetry;  on  the 
contrary,  it  is  bad  work,  and  is  most  unfair  to  the  patient.  It  will  not 
reveal  the  presence  of  a  Roenne's  step,  nor  will  it  give  a  true,  or  even 
an  approximately  true,  idea  of  the  state  of  the  visual  field. 

One  point  more  deserves  to  be  remembered:  The  glaucomatous 
patient  is  sensitive  to  changes  in  light,  and  it  is  therefore  important 
that  periodical  examinations  of  his  field  should  be  made  as  nearly  as 
possible  under  the  same  conditions  of  illumination.  It  is  difficult  to 
obtain  these  by  daylight  in  northern  latitudes,  and  for  this  reason, 
self -lit  instruments  or  those  illuminated  by  artificial  light  are  unques- 
tionably preferable  to  daylight  apparatus.  At  the  same  time,  it  is 
very  important  to  know  the  limitations  of  the  instrument  we  use; 
these  can  be  learned  only  by  constant  practice.  Under  no  circumstances 
must  either  the  fixation  or  the  traveling  object  be  too  bright.  If  it  is 
so,  the  patient  will  soon  become  fatigued,  while  before  this  happens, 
the  limits  of  his  field  will  be  exaggerated. 

SCOTOMETRY  OR  CENTRAL  PERIMETRY. — Bjerrum  was  the  first  to 
point  out  that  in  glaucoma  we  commonly  meet  with  arc-like  sco- 
tomata,  which  are  connected  with  the  blind  spot,  and  which  curve 
round  the  center  of  the  field  of  vision  to  end  on  the  horizontal  raphe. 
Such  scotomata  may  be  met  with  above  the  horizontal  raphe",  or  below 
it,  or  in  both  situations  simultaneously.  In  the  last  case  we  get  ring 
scotomata.  He  maintained  that  these  scotomata  were  the  expression 
of  lesions  of  nerve-fiber  bundles  at  the  edge  of  the  disc. 


The  Diagnosis  of  Glaucoma  421 

Roenne,  working  on  Bjerrum's  hypothesis,  looked  for  and  found  the 
sign,  which  is  called  by  his  name,  and  which  we  have  already  spoken 
of  in  connection  with  perimetry  of  the  whole  field  of  vision. 

Seidel  went  a  step  farther,  and  showed  that  very  early  in  glaucoma, 
before  any  other  sign  of  the  disease  could  be  certainly  recognized,  an 
enlargement  of  the  blind  spot,  either  upward,  or  downward,  or  both, 
could  be  detected  with  certainty  in  a  number  of  cases.  These  enlarge- 
ments were  always  described  as  ending  in  single  pointed  or  rounded 
ends.  From  the  first,  it  appeared  to  the  writer  that  this  clinical 
feature  was  inconsistent  with  the  accepted  pathology  of  the  condition, 
for,  if  it  were  a  question  of  a  lesion  of  a  number  of  bundles  of  nerve 
fibers  selected,  as  it  were,  out  of  the  whole  mass  of  the  nerve,  it  would 
only  be  reasonable  to  expect  that  the  lesions  they  would  sustain  would 
vary  widely  amongst  themselves,  and  that  therefore  the  scotoma  pro- 
duced would  not  end  in  a  point  but  in  a  number  of  points.  Experi- 
ments with  Bjerrum's  screen  and  with  other  apparatus  of  a  similar 
nature  failed  to  confirm  this  suggestion,  until  the  writer  devised  the 
scotometer  which  bears  his  name.  Then  the  scotoma  with  jagged 
points  was  at  once  found,  and  has  since  proved  to  be  so  consistent  a 
manifestation  as  to  make  the  appearance  of  this  phenomenon  of  high 
diagnostic  value. 

Three  principles  are  involved  in  the  make-up  of  this  apparatus: 
(1)  That  of  the  circular,  instead  of  the  radial,  method  of  examination 
of  the  field  of  vision,  as  advocated  by  Priestley  Smith ;  (2)  that  of  the 
magnification  of  the  scale  on  which  the  phenomena  are  observed,  so 
making  the  results  easier  to  obtain  and  more  striking  to  the  examined 
eye,  as  advocated  by  Bjerrum;  and  (3)  that  of  the  examination  of  the 
field  at  intervals  of  1°  instead  of  at  those  of  5°  or  10°  as  is  so  often  done. 
This  last  was  a  device  which  suggested  itself  to  the  writer's  mind  as 
likely  to  bring  out  the  jagged  nature  of  the  scotoma;  if  this  could  by 
any  means  be  accomplished. 

It  has  been  pointed  out  by  some  that  the  writer's  sign  is  not  ob- 
tained by  other  forms  of  scotometric  apparatus,  and  it  has  conse- 
quently been  suggested  that  it  is  an  artefact.  That  this  argument  is 
not  a  very  strong  one  is  clear  from  the  fact  that  the  sign  in  question 
has  been  obtained  in  glaucoma  cases  by  a  number  of  reliable  observers, 
who  have  abundantly  confirmed  the  writer's  findings  with  this  instru- 
ment. A  little  consideration  will  show  that  when  dealing  with  glau- 
coma cases  it  would  be  only  natural  to  expect  more  accurate  results 
from  the  Elliot  instrument  than  from  an  ordinary  scotometer,  and  this 


422  R.  H.  ELLIOT 

for  the  following  reasons:  (1)  As  has  already  been  shown,  the  circular 
method  has  special  advantages  in  dealing  with  scotomata  which  are 
the  result  of  lesions  to  nerve  fibers  at  the  edge  of  the  optic  disc;  for 
these  fibers  sweep  in  curves  around  the  central  area  of  vision  to  reach 
the  horizontal  raphe;  and  it  is  always  much  easier,  both  for  the 
surgeon  and  for  the  patient  if,  in  mapping  a  scotoma,  we  pass  through 
its  longest  and  not  through  its  shortest  axis.  Moreover,  in  the  author's 
experience,  a  scotoma  will  always  be  carried  further,  and  therefore 
shown  to  the  greatest  advantage,  if  we  pass  from  the  blind  in  to  the 
seeing  area,  instead  of  in  the  opposite  direction.  (2)  One  can  explore 
the  whole  field  out  to  the  26°  circle  at  1°  intervals  by  means  of  26 
circles  easily,  accurately,  and  mechanically  traced  for  us  by  a  rotating 
disc;  whereas  to  do  this  at  the  same  intervals,  working  radially  from 
the  center  would  demand  360  observations  and  would  hopelessly  tire 
our  patient.  Moreover,  the  closely  set  radial  lines  would  for  the  first 
ten  or  fifteen  degrees  be  practically  impossible  to  dissociate  from  one 
another.  (3)  Whatever  may  be  the  verdict  of  other  surgeons,  nothing 
can  shake  the  writer's  conviction  that  the  magnification  of  scotomata, 
whether  these  be. physiologic  or  pathologic,  makes  the  patient's  task 
enormously  easier,  and  the  surgeon's  results  much  more  accurate. 

THE  NORMAL  BLIND  SPOT,  as  mapped  out  by  the  new  instrument, 
does  not  differ  materially  from  the  records  of  other  instruments  em- 
ployed for  the  same  purpose.  This  is  all  the  more  important  since  the 
field  changes  which  it  reveals  in  glaucoma  are  so  very  distinctive.  We 
shall  now  consider  these: 

1.  THE  JAGGED  ENLARGEMENT  OF  THE  BLIND  SPOT  (FiG.  3). — This 
is  so  marked  a  feature  in  many  cases  that  it  cannot  easily  be  missed 
by  any  one  who  works  with  reasonable  care.    Even  in  quite  early  cases 
the  pointed  enlargement  of  the  normal  physiologic  scotoma  may  be 
highly  suggestive  of  the  presence  of  intraocular  pressure. 

On  the  other  hand,  if,  under  this  test,  we  find  the  blind  spot  of 
absolutely  normal  size  in  a  suspected  eye,  we  must  regard  this  negative 
evidence  as  of  great  value  in  suggesting  that  there  is  no  rise  of  intra- 
ocular pressure  present,  or  at  least  that  any  such  rise  that  may  be, 
or  may  have  been,  present  has  probably  up  to  date  done  no  harm. 

2.  DETACHED    PARACENTRAL    SCOTOMATA. — A    certain    amount, 
though  not  a  great  deal,  has  been  written  about  scotomata  in  glau- 
comatous  eyes  which  are  found  at  some  little  distance  from  the  blind 
spot.     Such  defects  are  not  infrequently  met  with  when  using  the 
author's  scotometer.    If  such  a  case  is  followed  for  some  <  ime,  these 


The  Diagnosis  of  Glaucoma 


423 


defects  can  often  be  traced  until  they  join  up  with  the  enlarged  blind 
spot.  They  are  obviously  due  to  lesions  of  those  nerve-fibers  which 
are  distributed  to  parts  further  away  from  the  disc.  Consider  for  a 
moment  a  bundle  emerging  from  the  optic  nerve  at  the  disc  edge. 
It  would  naturally  be  expected  that  the  fibers  which  would  be  earliest 
and  most  damaged  would  be  those  on  the  periphery  of  the  nerve; 
such  a  lesion  would  be  evidenced  by  an  enlargement  of  the  blind  spot. 
If,  however,  those  fibers  which  are  distributed  to  the  area  of  the 


Fig.  4. — Defect  in  the  same  case  as 
Fig.  3,  ten  days  after  relief  of  tension 
by  a  successful  trephining.  The 
pointed  peculiarity  can  still  be  traced 
in  this  scotoma. 


Fig.  3. — Defect  mapped  out  by 
author's  scotometer  in  an  early  case  of 
glaucoma  a  few  days  before  operation. 
Note  the  irregularity  of  the  endings  of 
the  upward  and  downward  extensions 
of  the  scotoma;  these  show  a  number 
of  points,  which  presumably  represent 
lesions  of  small  bundles  of  fibers. 

The  test-object  in  both  examinations  was  a  2  mm.  disc  of  white  blotting  paper. 
Each  circle  represents  5°. 

P.  S. — A  third  test  was  made  six  weeks  after  the  operation,  and  the  blind  spot 
was  then  found  to  be  practically  normal,  having  undergone  a  considerable  further 
contraction. 


retina,  represented  by  that  portion  of  the  field  close  to  the  horizontal 
raphe,  happen  to  be  earliest  damaged,  we  get  one  of  these  detached 
paracentral  scotomata  close  to  the  horizontal  meridian.  Again,  if 
some  of  the  intermediate  fibers  are  damaged,  we  get  a  scotoma  in  a 
corresponding  position  somewhere  along  the  curved  arc  of  the  course 
of  the  bundle. 

In  explanation  of  these  vagaries  in  the  scotometric  phenomena,  the 
following  considerations  may  be  suggested:  (a)  The  bundles  at  the 
periphery  of  the  nerve  are  most  liable  to  be  damaged  by  the  sharp 


424  R.  H.  ELLIOT 

edge  of  the  scleral  ring  over  which  they  curve  to  reach  the  retinal  sur- 
face, (b)  The  central  bundles,  destined  for  the  more  peripheral  parts, 
are  more  likely  to  be  injured  by  the  overstretching  to  which  they  are 
subjected  when  the  nerve  is  pushed  back  under  pressure,  (c)  Varia- 
tions in  the  anatomic  arrangements  of  the  nerve-fiber  bundles  them- 
selves may  possibly  explain  some  of  the  discrepancies  in  the  phe- 
nomena observed,  (d)  There  are  considerable  anatomic  variations 
in  the  supporting  framework  of  the  optic  nerve-head,  and  it  is  highly 
probable  that  consequently  the  nerve-head  yields  differently  in  dif- 
ferent eyes,  and  unevenly  in  the  same  eye.  We  are  therefore  justified 
in  expecting  that  the  injury  inflicted  will  vary  from  case  to  case,  and 
so  will  materially  influence  the  signs  of  disease  presented  by  the 
perimetric  picture. 

3.  INVASIONS  OF  THE  CENTRAL  AREA  OF  THE  FIELD.— The  surgeon 
who  employs  the  writer's  scotometer  as  a  routine  step  in  the  examina- 
tion of  his  glaucoma  cases,  will  be  surprised  to  find  how  often  the  cen- 
tral area  of  the  field  is  affected  in  eyes  in  which,  under  an  ordinary 
superficial  examination,  he  would  not  have  suspected  any  such  defect. 

This  is  a  matter  of  great  interest  and  importance.  The  writer  has 
seen  patients  whose  medical  men  believe  that  they  were  holding  their 
own,  and  whose  fields,  taken  on  an  ordinary  small  radius  perimeter, 
supported  such  a  view,  and  yet  they  themselves  were  firmly  con- 
vinced that  they  were  losing  ground,  as  indeed  they  were;  careful 
scotometry  at  once  showed  that  they  had  good  reason  for  their  com- 
plaints. The  value  of  the  writer's  instrument  in  explaining  such  cases, 
in  following  doubtful  eyes  before  coming  to  a  decision  as  to  operation, 
and  in  gauging  the  effect  of  operative  or  other  treatment  must  be 
experienced  to  be  appreciated. 

The  invasions  of  this  area  of  the  field  tend  to  move  steadily  onward 
toward  the  obliteration  of  the  upper,  or  of  the  lower,  central  field,  or  of 
both.  Two  clinical  types  are  thus  evolved:  (1)  When  the  scotoma  is 
confined  to  either  the  upper  or  the  lower  field,  the  condition  may 
amount  to  a  nearly  complete  central  hemianopia,  before  the  patient 
is  aware  of  the  serious  defect  in  his  vision.  This  can  only  be  the  case 
when  the  opposite  eye  is  comparatively  normal.  For  obvious  reasons 
the  hemianopia  is  always  superior  or  inferior  and  never  lateral.  (2) 
When  the  invasion  of  the  central  field  takes  place  simultaneously 
above  and  below  the  horizontal  meridian,  the  patient  is  more  likely  to 
detect  it  at  an  early  date.  The  progress  of  the  formation  of  a  ring 
scotoma  can  be  watched  in  such  cases  throughout  its  stages. 


The  Diagnosis  of  Glaucoma  425 

The  diversity  met  with  in  different  glaucoma  fields  has  already  been 
commented  on,  and  some  indication  of  its  various  causes  has  been 
furnished.  We  must  now  shortly  discuss  the  influence  of  the  incursion 
of  the  vascular  factor  on  the  broad  features  of  these  fields.  As  has 
already  been  pointed  out,  the  field  changes  which  are  due  to  the 
mechanical  effects  of  intraocular  pressure,  owe  their  variations  to 
anatomic  differences  in  the  supporting  framework  of  the  nerve-head, 
and  in  the  arrangement  of  the  fibers  of  the  nerve.  If  the  congestive 
element  could  be  excluded  entirely  from  a  case,  we  should  get  very 
different,  but  always  clear-cut,  perimetric  pictures,  and  from  these  we 
would  be  able  to  speak  with  very  little  hesitation  as  to  the  nature  and 
extent  of  the  damage  which  has  been  inflicted  on  the  optic  nerve. 
This,  however,  is  far  from  being  the  case.  The  element  of  congestion 
has  to  be  reckoned  with  in  most  instances.  (1)  In  some  it  dominates 
the  whole  picture,  blurring  all  details  like  a  fog  lying  across  a  land- 
scape; (2)  in  others  it  modifies  our  findings  to  a  considerable  extent, 
and  yet  we  may  be  quite  unable  to  apportion  the  just  amount  of  blame 
to  the  two  great  factors,  (a)  the  mechanical,  modified  by  anatomic 
circumstances,  and  (b)  the  congestive ;  (3)  in  yet  others  the  vascular 
factor  is  so  weak  that  it  is  with  the  utmost  difficulty  we  can  trace  its 
influence.  This,  however,  we  may  say  truly,  that,  while  simple 
glaucoma  tends  to  produce  definite  and  uneven  curtailments  of  the 
field,  the  entry  of  the  vascular  factor  blots  out,  or  tends  to  blot  out, 
the  sensitiveness  of  the  whole  retinal  area. 

TONOMETRY 

There  are  comparatively  few  ophthalmic  surgeons — and  probably 
none  in  America — who  do  not  make  abundant  use  of  one  or  another 
form  of  tonometer.  Even  the  student  of  to-day  is  trained  to  employ 
this  instrument  just  as  naturally  as  he  does  the  thermometer  or  the 
binaural  stethoscope.  The  ophthalmologist  who  does  not  do  so  fails 
in  his  duty  to  his  patients  and  is  an  anachronism.  Some  of  us  use  the 
Schiotz,  some  the  Gradle,  and  some  the  McLean.  It  matters  com- 
paratively little  which  model  we  adopt  so  long  as  we  keep  to  one  and 
learn  to  understand  its  indications.  Nor  is  it  a  matter  of  any  great 
importance  from  the  clinical  point  of  view  that  the  translated  reading 
in  mm.  Hg  may  not  accurately  represent  the  intraocular  pressure  in 
the  eyes  measured.  We  cannot  fix  for  any  tonometer  a  point  below 
which  the  recorded  pressure  is  certainly  normal,  or  a  corresponding 
point  above  which  it  is  supernormal,  for  we  know  that  the  pressure 


426  R.  H.  ELLIOT 

may  vary  considerably  in  different  normal  eyes;  what  may  be  low 
for  one  may  be  normal  for  another,  and  what  may  be  normal  for  a 
third  may  be  high  for  a  fourth.  It  is  to  take  an  altogether  perverted 
view  of  the  use  of  a  tonometer  to  regard  its  readings  as  if  they  were 
of  the  nature  of  a  scientific  laboratory  experiment.  They  are  nothing 
of  the  sort,  and  it  may  be  a  long  time  before  they  ever  become  as 
accurate  as  this.  On  the  other  hand,  the  indications  they  do  give  us 
are  of  the  greatest  possible  value:  (1)  In  a  very  large  number  of  cases 
they  tell  us  most  definitely  whether  the  intraocular  pressure  is  dis- 
tinctly high  or  normal.  (2)  When  the  pressure  is  different  in  the  two 
eyes, — and  especially  if  there  are  other  indications  of  glaucoma  in  the 
higher  tension  eye, — we  are  confronted  with  a  very  strong  suggestion 
that  a  pathologic  rise  in  pressure  is  present.  (3)  Variations  in  the 
pressure  of  an  individual  eye,  occurring  from  time  to  time,  afford  us  a 
most  valuable  criterion  of  the  progress — favorable  or  otherwise — that 
the  case  is  making,  and  of  the  value  of  the  medicinal,  operative,  or 
other  means  that  we  are  employing  in  the  treatment  of  the  case.  In 
this  connection  Butler's  tonometer  charts  deserve  a  mention,  as  they 
enable  the  surgeon  to  follow  up  his  cases  at  a  glance. 

It  must  be  made  quite  clear  that  nothing  which  has  been  written 
above  is  meant  as  a  criticism  of  the  effort  which  have  been  made  to 
standardize  the  Schiotz  tonometer.  Such  an  aim  is  altogether  desira- 
ble, and  I  would  like  to  pay  here  a  tribute  of  admiration  to  the  splen- 
did work  done  in  this  field  by  American  surgeons  and  especially  by 
McLean. 

THE  LIGHT-SENSE 

There  can  be  no  question  that  the  light-sense  is  profoundly  affected 
in  glaucoma.  We  know  this  well  from  the  bitter  complaints  of  our 
patients.  They  frequently  tell  us  of  their  difficulties  when  they  pass 
from  light  into  darkness  or  vice  versa.  Moreover,  bright  days  dazzle 
them,  while  in  dull,  cloudly  weather  they  have  difficulty  in  finding 
their  way  about.  An  examination  of  the  light-sense  ought,  therefore, 
to  be  productive  of  valuable  data.  It  has  been  claimed  by  reliable 
British  writers  that  in  the  earlier  stages  of  glaucoma  there  is  a  rapid 
reduction  in  light  minimum  sense,  but  only  a  very  slight  reduction  in 
the  light  difference  sense,  while  in  incipient  atrophy,  the  reverse  is  the 
case.  On  the  other  hand,  French  writers  have  obtained  diametrically 
opposite  results,  finding  the  light  difference  sense  the  first  to  be  at- 
tacked, and  the  light  minimum  sense  to  be  diminished  only  in  the 


The  Diagnosis  of  Glaucoma  427 

presence  of  optic  atrophy.  The  writer  has  been  very  much  troubled 
over  this  question:  He  has  met  with  well-established  cases  of  glau- 
coma in  which  the  light-sense,  tested  by  various  instruments,  does  not 
appear  to  be  inferior  to  the  normal,  either  in  minimum  or  in  difference, 
and  yet  the  patients  undoubtedly  suffer  when  their  light  is  reduced. 
He  suggests  as  a  possible  explanation  that  the  central  light-sense,  like 
the  central  visual  acuity,  may  long  remain  practically  normal,  while  the 
peripheral  light-sense  may  share  the  deterioration  with  which  we  are 
so  familiar  at  the  boundaries  of  the  visual  field.  The  writer  would 
emphasize  that  he  in  no  way  wishes  to  set  up  his  own  opinions  on  the 
subject  against  those  whose  findings  differ  from  his,  and  that  the 
remarks  he  has  now  made  on  the  subject  are  merely  a  call  to  other 
workers  to  persist  in  unravelling  a  tangled  skein.  Nor  is  the  interest 
of  the  subject  purely  academic;  on  the  contrary,  the  most  valuable 
results  from  the  point  of  view  of  the  early  diagnosis  of  the  disease  may 
well  spring  from  such  work  as  is  now  suggested.  It  could  not  fail  to 
be  of  interest  if  members  of  the  Congress  would  give  their  views  on  the 
best  pattern  of  photometer  for  use  in  the  examination  of  glaucoma 
patients,  and  if  they  would,  at  the  same  time,  indicate  the  means  they 
employ  for  differentiating  central  and  peripheral  acuity  of  vision  for 
light. 

CONCLUSION 

This  paper  has  endeavored  to  take  up  and  deal  with  a  few  of  the 
less  well  understood  aspects  of  the  diagnosis  of  glaucoma.  The  sub- 
ject is  far  too  vast  to  be  treated  at  length  and  the  writer  is  deeply 
conscious  of  the  many  deficiencies  of  his  contribution.  There  are  cer- 
tain points  that  he  would  like  to  insist  upon  with  the  utmost  emphasis : 

1.  In  order  to  decide  whether  glaucoma  is  present  or  not,  the 
patient  should  be  exhaustively  examined.  This  is  a  long,  painstaking, 
and  fatiguing  business,  and  cannot  be  accomplished  at  one  sitting,  or 
the  subject  will  become  overtired,  and  the  data  collected  will  be  un- 
trustworthy. Given  time,  patience,  and  suitable  equipment,  any  sur- 
geon should  be  able  to  make  up  his  mind  definitely  either  (a)  that  a 
patient  has  glaucoma  and  requires  treatment,  or  (b)  that  he  has  not 
got  glaucoma,  or  (c)  that,  in  the  absence  of  definite  and  distinct  signs 
of  the  disease,  the  case  should  be  followed  and  watched  until  an  un- 
hesitating opinion  is  arrived  at.  No  means  should  be  neglected  to 
make  the  diagnosis  as  precise  as  possible;  the  history  should  be  taken; 
a  routine  inspection  of  the  eye  should  be  made  in  a  good  light  without 


428  R.  H.  ELLIOT 

any  form  of  apparatus,  and  later  an  examination  by  oblique  illumina- 
tion with  the  aid  of  a  corneal  loupe;  the  refraction  should  be  carefully 
estimated ;  the  corneal  diameter  and  the  depth  of  the  chamber  should 
be  measured;  further  details  should  be  sought  for  with  the  corneal 
microscope,  the  field  being  illuminated  by  a  Gullstrand  lamp;  the  pos- 
sibilities of  ophthalmoscopy,  perimetry,  scotometry,  tonometry,  and 
photometry  should  be  exploited  to  the  full;  halos,  if  present,  should 
be  measured.  Then,  if  the  surgeon,  having  thus  made  the  most  of  the 
means  at  his  disposal,  is  still  in  doubt,  he  has  little,  if  anything,  to  lose 
by  watchful  waiting. 

2.  The  second  point  is  the  complement  of  the  first :  A  diagnosis  of 
glaucoma  should  never  be  made  on  any  one  sign  or  symptom,  no  mat- 
ter how  suggestive  that  may  be.    Such  a  course  can  never  be  necessary, 
and  is  not  justifiable. 

3.  Once  glaucoma  has  been  definitely  diagnosed,  the  patient  should 
be  very  carefully  watched,  and  if  he  is  going  downhill,  in  spite  of  gen- 
eral and  therapeutic  treatment,  an  early  operation  should  be  under- 
taken to  reduce  the  intraocular  pressure.    The  recurrence  of  congestive 
attacks  is  a  strong  indication  for  a  decompression  operation.    One  of 
the  most  delicate  tests  of  such  recurrences  is  the  observation  by  the 
patient  of  halos  around  lights.    If  the  congestive  attacks  are  well 
marked,  the  diagnosis  is  obvious;  it  is  only  in  the  very  mild  subacute 
exacerbations  of  glaucoma  that  we  need  to  rely  on  such  a  test. 

In  those  cases  where  all  evidence  of  congestion  is  absent,  we  must 
look  for  our  indications  to  scotometry,  perimetry,  tonometry,  oph- 
thalmoscopy, the  testing  of  central  visual  acuity,  etc.  The  order  is 
deliberate,  and  indicates  the  writer's  views  as  to  the  relative  impor- 
tance of  the  methods. 

Much  has  been  said  and  written  about  an  exaggerated  tendency  to 
resort  to  operation  for  glaucoma.  What  has  impressed  the  author 
more  than  anything  else  in  connection  with  this  disease  during  the 
eight  years  that  he  has  practised  in  Europe,  has  been  the  inclination, 
even  of  very  able  surgeons,  to  postpone  a  glaucoma  operation  if  it  is 
possible  to  do  so.  He  believes  that  where  one  operation  is  undertaken 
too  early,  very  many  are  put  off  till  far  too  late.  From  the  days  of 
von  Graefe  and  de  Wecker  onward,  it  has  been  a  guiding  surgical 
principle  that  the  earlier  an  operation  is  undertaken  for  the  relief  of 
glaucoma  the  better  is  the  prospect  of  success.  It  is  the  operations 
performed  at  a  late  stage  which  give  us  the  worst  results,  and  the  later 
the  stage  the  worse  the  prognosis. 


The  Diagnosis  of  Glaucoma  429 


DISCUSSION 

DR.  JOHN  E.  WEEKS  (New  York  City) :  I  would  like  to  emphasize  one  or 
two  points.  One  is  in  regard  to  the  cupping  of  the  disc.  In  the  very  early 
stage  of  glaucoma  we  may  have  a  cupping  beginning  at  one  margin  of  the 
disc,  that  is,  the  bending  of  the  vessels  will  be  evident  perhaps  only  at  the 
lower  margin,  or  perhaps  at  the  upper  margin  of  the  disc.  I  have  recently 
read  a  statement  by  a  German  authority  claiming  that  all  bending  of  the 
vessels  at  the  margin  of  the  disc  indicates  glaucoma,  and  I  am  inclined  to 
agree  with  him  in  that  respect.  Another  point  is  the  repeated  examination 
with  the  tonometer  of  the  tension  of  the  eyeball  in  all  suspected  cases. 

DR.  LUTHER  C.  PETER  (Philadelphia):  The  cornerstone  of  Col.  Elliot's 
carefully  constructed  diagnostic  symptom-complex  of  glaucoma  is  found  in 
the  first  clause  of  his  summary — namely,  an  exhaustive  examination.  Two 
of  the  important  signs  in  this  disease  are  field  studies  and  tonometry.  They 
are  most  important  because  they  not  only  are  "high  spots"  in  establishing  a 
diagnosis,  but  are  the  factors  upon  which  we  largely  determine  the  general 
management  of  a  case.  , 

His  statement  as  to  what  should  be  our  practice  in  tonometry  is  timely  and 
logical.  It  matters  little  what  instrument  is  employed  in  measuring  approxi- 
mately intra-ocular  tension,  provided,  as  he  says,  "we  keep  to  one  and  learn 
to  understand  its  indication."  Imperfect  though  it  may  be,  it  serves  to 
relatively  determine  whether  the  intra-ocular  tension  is  too  high  for  safety  as 
compared  with  the  other  eye.  When  used  with  routine  care  and  the  skill 
acquired  by  frequent  measurements,  any  of  the  instruments  mentioned,  and 
others  as  well,  will  serve  a  useful  purpose,  until  an  instrument  of  greater 
accuracy  and  better  adapted  for  routine  clinical  work  will  be  available. 

In  the  matter  of  field  studies,  peripheral  changes  and  central  disturbances 
are  important.  Peripheral  changes,  especially  in  the  nasal  quadrant,  are 
early  phenomena,  but,  as  Col.  Elliot  has  pointed  out,  we  are  not  so  careful 
to  search  for  these  errors  as  we  might  be.  This,  however,  is  due  largely  to 
the  inadequacy  of  the  instruments  at  our  disposal — a  phase  of  our  work  which 
we  hope  the  Ferree  perimeter  will  remedy. 

More  vital  even  than  the  early  peripheral  changes  are  those  found  in  the 
paracentral  field,  because  their  presence  means  that  the  process  has  advanced 
to  dangerous  limits,  and  that  surgical  intervention  can  no  longer  be  side- 
stepped either  by  patient  or  surgeon.  The  slightest  evidence  of  a  begin- 
ning Bjerrum  sign,  whether  it  appears  first  at  the  margin  of  the  blind 
spot,  or  above  or  below  the  point  of  fixation,  speaks  for  surgical  in- 
terference. The  development  of  this  sign  is  most  interesting.  In  not 
a  few  cases  it  has  its  origin  at  the  upper  or  lower  temporal  margin  of 
the  blind  spot — the  so-called  Seidel  sign,  but  really  only  a  variation  in  the 
beginning  of  a  typical  Bjerrum  scotoma.  More  frequently,  in  the  speak- 
er's experience,  it  has  its  beginning  above  or  below  the  point  of  fixation 
between  the  10th  and  20th  meridians.  The  earliest  evidence  of  its  presence 
may  be  detected  by  a  half-degree  test  object  for  green  or  red,  either  at  close 
range  or  at  a  meter's  distance.  When  found  in  this  location,  it  enlarges 


430  R.  H.  ELLIOT 

toward  the  blind  spot  and  toward  the  periphery — at  times  toward  the  raphe", 
where  it  may  meet  a  similar  scotoma  from  the  opposite  half  of  the  field  and 
from  a  ring  scotoma.  At  times  the  blind  spot  may  show  an  enlargement  and 
at  the  same  time  the  area  above  or  below  the  fixation  point  may  undergo 
relative  or  absolute  changes  simultaneously,  with  healthy  retina  intervening. 
If  increased  intra-ocular  tension  is  not  checked,  the  two  areas  will  finally  unite 
and  the  typical  Bjerrum  sign  will  appear.  This  sign  may  be  present  without 
alarming  changes  in  the  peripheral  field.  If  not  sought  for  assiduously,  the 
false  assurance  that  all  is  well  because  the  peripheral  field  is  of  good  size  may 
lead  to  error.  It  is  the  sign  which  the  author  searches  for  with  the  most 
delicate  test  available,  and  it  is  the  recovery  from  this  sign  in  its  relative  or 
absolute  stage  that  determines  the  efficacy  of  the  surgical  measure  practised. 
When  the  scotoma  is  fully  developed  and  extends  to  the  periphery,  the  border 
lines  of  the  destroyed  nerve  bundles  may  be  watched  with  equal  interest  to 
determine  whether  the  surgical  measures  practised  are  holding.  Its  exten- 
sion is  the  most  delicate  indication  for  further  surgical  interference. 

As  to  the  best  method  of  determining  even  slight  enlargements  of  the  blind 
spot,  there  is  much  room  for  argument.  There  can  be  no  doubt  that  the 
methodical  method  of  approach  as  practised  by  Col.  Elliot  will  uncover  a 
blind  area  if  present — not  only  because  he  determines  the  outline  by  a  circular 
motion  but  because  his  method  is  painstaking  and  methodical.  The  same 
area  can  be  plotted  by  the  more  flexible  hand  method,  which,  if  practised  in 
the  same  methodical  and  accurate  manner,  must  yield  even  more  accurate 
results  than  those  of  a  mechanically  operated  instrument.  It  is  a  matter  of 
common  knowledge  that  the  points  on  the  scleral  edge  of  the  disc  where  the 
retinal  fibers  are  most  apt  to  suffer  compression  are  not  necessarily  at  the 
extreme  upper  and  lower  boundaries  but  on  the  temporal  side,  involving 
the  upper  and  lower  quadrants.  Using  the  blind  spot,  therefore,  as  a  center 
of  study  a  radial  movement  of  the  stimulus  is  apt  to  uncover  the  total  de- 
fect quite  as  well  as  a  meridional  movement.  Equally  good  results,  how- 
ever, can  be  obtained  by  not  limiting  oneself  to  either  a  meridional  or 
radial  movement,  but  by  practising  a  freehand  movement  in  all  directions 
which  will  bring  out  the  defect  as  it  exists. 

MR.  E.  TREACHER  COLLINS  (London,  England) :  I  should  like  to  emphasize 
some  of  the  points  made  by  Col.  Elliot  and  the  last  two  speakers.  First, 
with  regard  to  the  halos  in  glaucoma.  As  Col.  Elliot  has  pointed  out,  they 
may  be  due  to  change  in  the  lens,  and  I  think  that  is  an  important  point  to 
remember.  Fine  changes  of  the  nucleus  of  the  lens,  sometimes  spoken  of  as 
sclerosis,  may  produce  persistent  colored  halos  around  lights.  I  have  seen 
a  patient  who  had  had  both  eyes  operated  on  because  of  halos  due  to  this 
condition  of  the  lens,  and  as  the  halos  persisted  after  the  operations  one  eye 
was  operated  on  a  second  time;  there  was  no  cupping  of  the  disc,  no  constric- 
tion of  the  field,  no  other  symptom  of  glaucoma.  I  have  several  patients 
with  this  condition  whom  I  have  watched  for  a  long  time,  but  no  symptoms 
of  glaucoma  have  developed. 

Then  it  is  necessary  to  make  our  patients  clearly  understand  what  we  mean 
by  "halos."  I  had  a  patient  come  to  me  some  years  ago  and  ask  me  to  tell 


The  Diagnosis  of  Glaucoma  431 

him  if  he  had  glaucoma.  I  examined  his  eyes  very  carefully  with  the  perim- 
eter, looked  into  them  with  the  ophthalmoscope,  but  found  no  signs  of 
glaucoma.  He  then  said  that  two  years  previously  an  ophthalmic  surgeon 
examined  him  as  I  did  and  then  asked  him  if  he  had  ever  seen  "rainbows." 
He  said  yes,  he  had,  and  this  surgeon  then  said,  "Well,  you  have  glaucoma." 
He  was  a  very  intelligent  man  and  he  went  home  and  got  a  medical  dictionary 
and  looked  up  all  he  could  find  about  glaucoma,  frightening  his  whole  family 
and  himself,  and  for  two  years  he  had  lived  in  trepidation.  Then  he  came  to 
me  and  I  told  him  he  had  no  glaucoma.  Several  years  have  now  elapsed  and 
no  symptoms  have  occurred. 

As  Col.  Elliot  says,  there  may  be  a  physiologic  appearance  of  colored  rings 
when  the  pupil  dilates.  I  know  a  member  of  our  own  fraternity  who  fre- 
quently sees  these  rainbow  rings,  especially  in  the  evening.  I  have  watched 
him  for  a  long  time — he  was  very  anxious  about  himself — but  he  has  never 
developed  any  signs  of  glaucoma. 

With  regard  to  Koepp's  sign,  there  is  much  to  be  learned.  It  is  not  present 
only  in  glaucoma.  It  can  be  seen  readily  with  a  Gullstrand  slit  lamp  or  by 
contact  illumination. 

With  regard  to  the  optic  disc,  I  think  an  early  symptom  of  glaucoma  is  the 
displacement  of  the  retinal  vessels  laterally  toward  the  nasal  side.  In  eyes 
where  there  is  definite  glaucoma  in  one  eye  and  in  the  other  perhaps  no 
marked  symptoms  one  may  see  this  lateral  displacement  of  vessels  towards 
the  nasal  side. 

One  word  in  regard  to  scotometry,  and  that  is  as  to  the  diagnosis  of  whether 
the  glaucomatous  process  has  been  checked  by  operative  procedure.  As 
previous  speakers  have  said,  the  field  may  show  no  increased  contraction, 
the  acuity  of  vision  may  remain  the  same  as  before  operation,  and  you  are 
inclined  to  say  the  operation  is  satisfactory;  but  the  patient  says  his  eyesight 
is  not  so  good  as  before.  If  you  try  scotometry  you  will  find  the  scotomatous 
area  has  extended  around  the  fixation  spot. 

Another  symptom  which  these  patients  sometimes  complain  of  is  that  they 
get  no  pleasure  from  reading.  They  may  have  6/6  vision,  but  they  do  not 
care  to  read,  and  I  think  the  reason  is  that  the  scotoma  is  spreading  around 
the  fixation  spot,  and  that  patients,  although  they  see  the  word  they  look  at, 
do  not  see  the  next  word,  so  the  pleasure  of  reading  for  them  is  gone. 

DR.  E.  E.  BLAAUW  (Buffalo,  N.  Y.) :  Col.  Elliot  said  it  is  a  simple  thing  to 
measure  the  depth  of  the  anterior  chamber,  but  I  think  it  is  difficult  to  know 
where  the  limits  are.  The  iris  margin  is  very  different;  the  pigment  of  the 
margin  has  a  different  size  and  extent;  the  cornea  is  not  of  the  same  thick- 
ness and  curvature  in  all  eyes;  where  are  we  going  to  take  the  measurement, 
in  the  periphery  or  the  center?  I  do  not  know.  The  change  of  the  cornea, 
which  has  appeared  to  me  in  many  instances  the  beginning  of  high  tension, 
may  be  considered  the  symptom  which  Stahli  called  "betauung."  It  is  only 
seen  when  the  epithelial  cells  form  small  blebs,  best  seen  in  reflected  light. 
In  my  very  limited  experience  I  have  thought  that  it  is  not  a  pathognomonic 
sign. 


432  R.  H.  ELLIOT 

I  am  a  little  surprised  that  Col.  Elliot  did  not  speak  of  gonioscopy.  This 
gives  us  a  new  method  of  attacking  the  anterior  angle. 

I  agree  that  Koeppe's  sign  does  not  include  deposits  on  the  posterior  layer 
of  the  cornea.  In  elderly  eyes  frequently  pigment  moves  away  from  the 
pupillary  iris  border.  Koeppe  values,  therefore,  fine  pigment  deposits  in  the 
crypts. 

DR.  J.  W.  NORDENSON  (Stockholm,  Sweden) :  The  discussion  having  also 
treated  of  the  methods  of  examining  eyes  in  reference  to  symptoms  of  glaucoma 
and  Col.  Elliot  having  requested  in  his  paper  members  of  the  Congress  to 
tell  their  ways  of  testing  the  light  sense,  I  venture  to  call  your  attention  to 
some  methods  of  investigation  that  are  practised  in  our  clinics.  In  testing 
the  light  sense  two  different  things  are  to  be  examined :  the  sense  for  light- 
differences  and  the  sense  of  light-perception.  The  testing  of  the  sense  for 
light-difference  will  be  dealt  with  later  in  a  paper  by  Dr.  Percival,  so  that 
solely  the  testing  of  light-perception  comes  in  question  here.  The  testing  of 
this  function,  which  nowadays  is  of  greatest  importance  in  examining  aviators 
and  motor  drivers,  is  done  in  our  clinics  with  an  instrument,  originally 
devised  by  Gullstrand  and  further  elaborated  and  described  by  S.  Lindquist 
of  Sodertalge.1  The  instrument  consists  of  a  box  containing  a  light  source  of 
constant  intensity  and  shut  at  one  end  by  a  milk-glass  plate  covered  by  a 
sieve  with  900  holes.  With  the  aid  of  two  slides  any  number  of  these  holes 
can  be  opened  and  shut  according  to  wish.  In  making  the  test  all  the  patients 
are  assembled  in  a  totally  dark  room  where  they  are  left  for  about  half  an 
hour  in  order  to  get  adapted  to  dark.  The  instrument  is  then  put  up  in  front 
of  a  square  piece  of  white  paper  of  certain  dimensions  and  the  holes  are  opened 
one  after  another  until  the  examined  patient  affirms  that  he  can  see  the  paper. 
The  intensity  of  light  coming  from  the  paper  when  lighted  by  one  hole, 
having  once  been  tested,  the  examination  gives  you  the  amount  of  light  re- 
quired to  give  the  patient  perception  of  light.  Simulation  is  avoided  by  re- 
peating the  test  several  times  and  by  comparing  the  number  of  holes  required 
each  time.  The  method,  which  is  a  modification  of  the  apparatus  of 
Foerster,  has  the  advantage  that  the  examiner  himself  need  not  be  adapted 
for  dark.  If  it  were  possible  to  devise  a  method  to  control  the  fixation  of 
the  patient,  it  would  be  possible  to  use  the  instrument  also  for  testing  the 
sense  of  light-perception  in  different  parts  of  the  retina. 

For  the  use  of  the  slit  lamp  to  measure  the  depth  of  the  anterior  chamber 
of  which  Dr.  Blaauw  spoke,  an  instrument  has  been  constructed  by  Lind- 
steadt  of  Stockholm.2  The  principle  of  it  is  that  the  pencil  coming  from  the 
slit  is  made  astigmatic  by  an  optic  system,  whereby  one  of  the  focal  lines 
is  placed  on  the  anterior  surface  of  the  cornea,  the  other  on  the  anterior  surf  ace 
of  the  crystalline.  With  knowledge  of  the  power  of  the  astigmatic  system 
that  is  required  to  so  adjust  the  focal  lines,  the  depth  of  the  anterior  cham- 
ber can  be  determined  very  exactly. 

MR.  J.  GRAY  CLEGG  (Manchester,  England):    Several  points  I  wish  to 

1  Upsala  Lakareforenings  forhandlingar,  1906. 

2  Arch.  f.  Augenheilkunde,  vol.  80. 


The  Diagnosis  of  Glaucoma  433 

mention,  and  one  is  that  in  making  a  diagnosis  we  cannot  rely  on  any  absolute 
line  as  to  the  height  of  pressure  when  determining  the  presence  of  glaucoma 
in  the  particular  eye  under  examination.  One  finds  a  considerable  variation, 
and  perhaps  this  is  well  illustrated  by  a  case  that  I  have  had  recently,  an 
iridocyclitis  with  high  tension,  but  where  there  was  perfect  peripheral  vision, 
no  scotoma,  no  enlargement  of  the  blind  spot,  but  the  tension  was  high — over 
40  mm.  It  was  only  after  some  months  of  treatment,  the  tension  remaining 
high,  that  slight  enlargement  of  the  blind  spot  was  found  and  operation  was 
resorted  to.  Other  cases  show  the  signs  of  chronic  glaucoma,  although  the 
tension  is  never  found  above  normal. 

In  the  old  days  my  predecessor,  Dr.  David  Little,  used  to  be  afraid  of  the 
iridectomy  operation  when  there  was  a  blind  area  near  the  fixation  point,  for 
fear  the  surgical  interference  might,  as  it  were,  tip  the  eye  over  the  precipice; 
but  we  find  that  with  the  trephining  operation  we  need  not  hold  back,  even 
though  the  blind  area  extends  within  two  or  three  degrees  of  the  central  point. 

Another  important  point  is  that  we  must  not  overlook  the  general  health  of 
the  patient. 

DR.  GEORGE  F.  KEIPER  (Lafayette,  Ind.) :  I  want  to  add  the  history  of  a 
patient  with  chronic  glaucoma,  who  before  I  first  saw  him  had  lost  one  eye, 
and  I  have  been  afraid  to  operate  on  the  other  eye,  and  have  been  controlling 
him  with  miotics.  When  I  drew  the  curtains  down  in  the  dark  room  he  said 
he  could  see  the  test  letters  better  when  the  room  was  brightly  illuminated. 
I  tried  that  with  him  a  number  of  times,  and  found  it  to  be  true.  I  now  make 
this  test  with  all  persons  over  the  age  of  forty,  and  if  I  find  they  can  see  the 
letters  in  the  dark  room  better  with  the  curtains  up  rather  than  in  a  shaded 
room,  my  suspicions  are  immediately  aroused,  and  I  am  inclined  to  think  of 
the  advice  Dr.  Ellett  gave  years  ago,  to  use  tonic  drops  of  eserin  in  order  to 
be  on  the  guard  against  cases  of  glaucoma  that  may  manifest  themselves  by 
any  other  symptoms. 

DR.  ARNOLD  KNAPP  (New  York  City) :  While  we  may  not  all  agree  on  the 
form  of  operation,  we  are  all  united  on  the  fact  that  the  value  of  any  treat- 
ment of  glaucoma  rests  in  the  early  diagnosis,  and  the  most  important  factor 
in  this  is  the  examination  of  the  paracentral  area  by  the  scotometer.  Al- 
though it  is  many  years  old,  the  profession  in  general  owes  Col.  Elliot  a  debt 
for  so  instructively  drawing  our  attention  to  this  method. 

The  other  point  I  wish  to  mention  is  that  among  the  early  signs  there  is  a 
curious  susceptibility  of  the  glaucomatous  eye  to  adrenalin.  In  some  in- 
vestigations made  and  reported  to  the  American  Ophthalmological  Society 
last  year,  I  drew  attention  to  the  fact  that  adrenalin  causes  a  dilatation  of  the 
pupil  in  glaucoma  in  nearly  all  cases.  In  some  cases  the  tension  was  reduced, 
in  some  it  remained  the  same,  and  in  a  few  it  was  increased.  When  adrenalin 
was  instilled  into  the  other  eye  which  has  had  no  symptoms  of  glaucoma,  a 
dilatation  of  the  pupil  was  observed. 

DR.  GEORGE  W.  JEAN  (Santa  Barbara,  Cal.) :  With  regard  to  the  loss  of 
blood-vessels  at  the  disc  edge,  which  Dr.  Weeks  said  he  had  recently  seen 
mentioned  in  a  foreign  text-book,  I  would  like  to  call  attention  to  the  fact 

28 


434  R.  H.  ELLIOT 

that  I  spoke  of  this  sign  in  my  text-book  published  in  1915.  Men  working 
under  Lauber  in  Vienna  a  dozen  years  ago  will  well  remember  how  he  insisted 
that  this  sign,  if  present,  was  an  absolutely  pathognomonic  sign  of  glaucoma. 
There  are  two  exceptions :  in  congenital  colobomas  of  the  nerve  head  and  also 
in  those  peculiar  cases  with  a  congenital  hole  in  the  disc  that  often  goes 
several  millimeters  deep.  Lauber  has  reported  several  cases  of  the  latter, 
and  I  have  seen  one  such  case  with  lost  vessels  at  the  disc  edge. 

Of  course,  the  sign  is  not  always  there,  but  with  the  exceptions  mentioned 
"the  short  bend  of  a  single  vessel  immediately  at  the  disc  edge  is  sufficient  in 
every  case  for  the  diagnosis  of  glaucoma." 

COL.  R.  H.  ELLIOT  (closing) :  With  regard  to  Dr.  Weeks'  remarks,  I  have 
observed,  as  he  says,  over  and  over  again,  that  cupping  occurs  first  at  one 
portion  of  the  disc,  and  I  think  that  is  explained  by  Fuchs'  recent  work  on 
the  difference  in  the  way  in  which  the  disc  yields  unevenly,  according  to  the 
state  of  the  distribution  of  the  fibrous  tissues  in  the  lamina  cribrosa.  I  am 
not  prepared  to  go  as  far  as  some  of  the  speakers  who  feel  that  a  single  vessel 
out  of  place  means  glaucoma,  because  I  have  seen  cases  where  vessels  at  one 
part  of  a  disc  were  suspicious,  but  when  the  cases  were  followed  for  a  long 
time  I  could  not  satisfy  myself  that  there  was  glaucoma  present.  At  the 
same  time,  though,  the  sign  always  makes  one  suspicious. 

I  would  like  to  press  home  what  Dr.  Peter  said  about  the  tonometer.  The 
tonometer  is  the  only  accurate  method  of  measuring  the  tension  of  the  eye, 
and  to  do  anything  else  is  equivalent  to  putting  your  hand  on  a  patient's 
skin  and  saying  he  has  a  temperature  of  102°.  I  also  agree  with  him  that 
when  paracentral  scotoma  is  present  a  dangerous  stage  has  been  reached,  and 
the  patient  should  be  watched;  also  that  detached  paracentral  scotoma  is 
extremely  common  in  glaucoma. 

All  I  claim  for  my  instrument  is  that  you  can  make  a  reliable  clinical  examina- 
tion in  a  remarkably  short  time  by  its  use.  I  have  never  put  it  forward  as  an 
instrument  for  scientific  research,  but  it  is  an  instrument  of  great  delicacy 
and  can  be  used  rapidly. 

Mr.  Collins  spoke  of  the  gentleman  who  saw  rainbows.  I  would  like  to 
pass  this  lycopodium  slide  around.  I  keep  it  in  my  dark  room  and  say  to  my 
patient,  "Have  you  ever  seen  halos?"  He  does  not  know.  Then  I  say, 
"Look  at  the  bright  light  through  this."  He  looks  and  knows  at  once  what 
we  mean  by  a  halo. 

Dr.  Blaauw  took  me  up  on  the  question  of  the  depth  of  the  chamber. 
When  I  wrote  that  I  had  no  idea  I  was  being  so  dogmatic.  That  was  written 
months  ago,  and  I  would  have  been  less  assertive  if  I  had  written  it  now, 
after  more  experience  with  the  Ulbrich  drum.  All  the  same,  I  believe  it  can 
be  made  a  useful  adjunct  to  diagnosis. 

With  regard  to  contact  glasses,  I  have  not  had  the  courage  yet  to  use  con- 
tact glasses,  but  I  am  in  hope  of  being  put  in  the  way  of  using  them.  I  admit 
it  is  an  important  matter. 

Dr.  Nordenson  spoke  of  a  light-sense  apparatus.  I  have  had  constructed 
for  me  by  Zeiss  an  apparatus  which  I  am  using  in  my  dark  room  and  which 
will,  I  think,  prove  useful. 


Blood-Pressure  in  the  Vessels  of  the  Eye  435 

Mr.  Clegg  raised  the  important  point  of  the  general  treatment  of  the  patient. 
Of  course  the  glaucomatous  individual  has  a  sick  eye  in  a  sick  body,  and  you 
must  examine  the  whole  patient. 

With  regard  to  Dr.  Keiper's  point,  the  thing  that  strikes  me  more  than 
anything  else  is  the  way  in  which  every  glaucomatous  patient  has  deficient 
light  sense,  and  yet  there  is  difficulty  in  getting  him  to  show  it  by  any  ordinary 
sort  of  apparatus.  The  explanation  that  I  offer  I  have  already  given  you 
elsewhere. 

I  think  Dr.  Knapp's  test  is  one  that  we  should  follow  very  carefully. 


BLOOD-PRESSURE  IN  THE  VESSELS  OF  THE  EYE 

DR.  A.  MAGITOT  AND  DR.  P.  BAILLIART 

Paris,  France 

It  has  long  been  known  that  a  slight  compression  of  the  eyeball 
causes  arterial  pulsation  in  the  retina.  Physiology  enables  us  easily 
to  understand  that  this  arterial  pulsation  appears  when  the  tension  of 
the  ocular  media  reaches  the  diastolic  pressure  of  the  central  artery 
of  the  retina.  Similarly,  we  knew,  that  the  pulsation  will  cease  when 
the  pressure  exercised  through  the  ocular  media  is  greater  than  the 
systolic  pressure  of  the  central  artery.  It  was  soon  discovered  that, 
in  the  case  of  patients  suffering  from  arterial  hypertension,  it  was 
necessary  to  exercise  on  the  eyeball  a  strong  pressure  to  bring  about 
the  disappearance  of  the  retinal  pulsation;  Bailliart  (1909),  then 
Melville  Black  (1911),  and-Deyl  (1912),  had  drawn  attention  to  this 
method  of  recognizing  the 'existence  of  arterial  hypertension. 

In  order  to  measure  the  arterial  pressure  in  the  central  artery  of  the 
retina,  it  remained  therefore  only  necessary  to  know  the  amount  of 
force  it  was  necessary  to  apply  to  the  eyeball,  to  bring  about  the 
appearance  and  disappearance  of  the  pulsation.  Henderson  had, 
for  this  purpose,  constructed,  as  early  as  1914,  an  apparatus  which 
calculated  in  millimeters  of  mercury  the  pressure  which,  exerted 
on  the  exterior  surface  of  the  eyeball,  was  sufficient  to  bring  about 
the  appearance  of  the  diastolic  pulsation.  Henderson  thought, 
which  is  not  altogether  incorrect,  that  by  adding  the  ocular  tension 
to  the  figure  given  by  his  apparatus,  he  would  get  the  diastolic  pressure 
of  the  central  artery. 

Bailliart,  in  1917,  suggested  a  method  for  determining  the  figures 
of  the  diastolic  and  systolic  pressures  of  the  central  artery.  By 


436  A.  MAGITOT  AND  P.  BAILLIART 

means  of  a  special  dynamometer,  graduated  in  grams  of  water  so 
that  it  might  be  easily  verified  on  any  scales,  a  pressure  is  exerted  on 
the  eye  in  the  region  of  the  insertion  of  the  rectus  externus,  until  the 
operator  notes  the  appearance  and  then  the  disappearance  of  the 
retinal  pulsation.  Two  successive  readings  will  thus  give  the  amount 
of  force  which  it  is  necessary  to  exert  to  balance  the  diastolic  and  then 
the  systolic  pressure  of  the  central  artery.  But  the  thing  that  it  is 
then  important  to  know  is,  how  the  primitive  ocular  tension  has  been 
modified  by  these  dynamometric  pressures,  for,  finally,  it  is  by  its 
intermediary  that  we  act  on  the  vessels  of  the  eye. 

Henderson  has  had  the  idea  of  measuring  in  millimeters  Hg  the 
pressure  exerted  on  the  eyeball  and  of  adding  to  it  the  ocular  ten- 
sion determined  by  means  of  Schiotz's  tonometer;  but  in  this 
method  there  is  a  double  cause  of  error,  first,  from  a  physical  point 
of  view,  two  successive  pressures  do  not  add  up  together,  and  on 
the  other  hand,  the  pressure  transmitted  by  a  liquid  is  proportional 
to  the  surface  compressed.  Here  is,  however,  another  method:  In 
a  dark  room,  the  patient  being  placed  in  a  recumbent  position,  the 
operator  causes  the  appearance  and  disappearance  of  the  pulsation 
and  notes  the  weight  in  grams  necessary  to  obtain  these  two  results. 
Then  Schiotz's  tonometer  is  applied  to  the  eye  while  at  the  same  time 
by  means  of  the  dynamometer  a  pressure  is  exerted  equal  to  that 
which  was  found  necessary  a  few  moments  before  to  produce  the  ap- 
pearance and  disappearance  of  the  pulsation.  The  tonometer 
weighted  with  its  heaviest  weight .  will  indicate  approximately  in 
millimeters  Hg  the  pressure  exerted  on  the  vessels  of  the  retina.  It 
is  evident  that  the  greater  the  pressure  exerted  on  the  eyeball  the 
greater  will  be  the  ocular  tension. 

But  this  method  complicates  the  operation  and  is  only  possible 
with  exceptionally  docile  subjects.  It  is  for  this  reason  that  we 
undertook  to  study  experimentally,  on  an  animal,  the  modifications 
of  the  intraocular  tension  under  different  pressures  and  to  draw  up  a 
chart.  But  to  be  of  use  clinically  the  knowledge  of  these  modifica- 
tions of  the  ophthalmotonus  caused  by  pressure  exerted  on  a  healthy 
or  diseased  eye,  must  apply  not  only  to  a  particular  case,  but  to  a 
whole  series  of  figures  of  initial  tensions.  The  method  would  indeed 
be  singularly  restricted,  if  we  only  knew  the  tensions  produced  by  a 
pressure  of  10,  20,  40  or  80  grams  on  an  eyeball  the  initial  ophthal- 
motonus of  which  would  be  uniformly  20  mm.  Hg.  It  is  indispensable 
to  acquire  a  knowledge  of  the  effect  produced  on  different  initial 


Blood-Pressure  in  the  Vessels  of  the  Eye  437 

ophthalmotonus,  for  we  must  evidently  suppose  that  the  same  pres- 
sure of  20  grams  will  produce  a  different  tension  in  an  eye  of  which 
the  primitive  ophthalmotonus  was  15  mm.  Hg  and  in  another  of 
which  the  ophthalmotonus  would  be  30  mm.  Hg. 

The  drawing  up  of  such  a  chart  was  possible  only  by  experiment. 
We  carried  out  researches  on  cats  anesthetized  with  chloralose,  this 
product  being  easier  to  manipulate  than  curare  and  causing  only  a 
slight  modification  in  the  general  blood-pressure,  on  condition  that 
the  animal  is  not  allowed  to  get  cold.  We  have  also  made  use  of  a 
mercury  manometer  invented  by  one  of  us  and  of  which  the  manipu- 
lation appears  to  us  to  be  easier  than  of  Wessely's  or  of  other  instru- 
ments derived  from  Schulten's. 

The  ocular  tension  of  the  cat  oscillates  between  15  and  25  mm.  Hg 
according  to  conditions.  It  was,  therefore,  relatively  easy  to  establish 
the  figures  of  ophthalmotonus  starting  from  these  initial  tensions. 
But  it  was  necessary  to  obtain  greater  tensions  and  others  still  weaker. 
We  were  able  to  produce  higher  starting  figures  by  practising  sub- 
conjunctival  injections  of  NaCl.  We  were  thus  able  to  obtain  quite 
easily  tensions  of  40  or  45  mm.  Hg,  rarely  more. 

In  order  to  operate  on  lower  ocular  tensions  than  15  mm.  Hg  we 
had  recourse  to  a  deeper  narcosis  in  order  to  act  upon  the  general 
blood-pressure.  But  we  were  unable  to  obtain  less  than  10  mm.  Hg 
which  in  the  cat,  as  in  man,  is  the  immediate  postmortem  tension. 

We  chose  the  cat  in  preference  to  the  rabbit  (which  is,  however, 
an  easier  animal  to  handle)  on  account  of  its  ocular  nervous  system, 
which  is  very  similar  to  that  of  man.  Yet  both  of  them  possess  a 
much  larger  anterior  chamber  and  we  do  not  know  whether  the 
general  elasticity  and  resistance  are  identical  with  those  of  the  human 
eye. 

We  have  avoided  producing  modifications  of  the  tonus  by  injection 
or  aspiration  of  the  intraocular  liquid  as  these  means  give  erroneous 
figures  for  the  two  following  reasons : 

1.  On  account  of  the  resorption. 

2.  On   account    of   the    intraocular   vasodilatation   which,    very 
probably,  takes  place  after  a  few  seconds.     As  to  the  pressures,  they 
are  made  by  means  of  Bailliart's  dynamometer,  which  is  either  held 
in  the  hand  or  immovably  fixed  in  a  ratchet-support. 

The  chart  on  next  page  will  avoid  any  useless  descriptions.  It  gives 
us  the  figures  for  pressures  applied  horizontally  (as  on  a  patient  sitting 
or  reclining)  on  eyeballs  of  which  the  initial  tensions  vary  from  10 


438 


A.  MAGITOT  AND  P.  BAILLIART 


mm.  to  50  mm.  Hg.  It  will  be  noted  that  the  different  lines  starting 
from  different  initial  tensions  are  remarkable  for  their  parallelism 
and  also  for  being  nearly  straight.  It  results  from  this  that  the 
chart  can  be  completed  for  all  the  initial  pressures  and  for  all  pres- 
sures applied. 


It  will  be  seen  that  with  this  chart  the  determination  of  diastolic 
or  systolic  arterial  pressure  in  the  branches  of  the  central  artery  be- 
comes easy. 

We  first  measure  with  Schiotz's  tonometer  the  initial  ocular  tension, 
then  we  seek  what  dynamometric  pressure  will  bring  about  the  ap- 


Blood-Pressure  in  the  Vessels  of  the  Eye  439 

pearance  and  later  the  disappearance  of  the  arterial  pulse.  We  then 
refer  to  the  chart  and  we  find  in  millimeters  Hg  the  required  figures. 
In  an  eye  of  normal  tension  in  a  eubject  whose  arterial  pressure  is 
normal,  the  arterial  retinal  pressure  is  about  35  mm.  for  the  diastolic 
and  70  mm.  for  the  systolic. 

If  the  retinal  circulation  has  a  primordial  importance  since  it 
insures  the  visual  function,  the  choroidal  circulation  also  plays  a 
considerable  part;  the  part  it  takes  in  the  modifications  of  the  oph- 
thalmotonus  is  well  known.  It  is  moreover  possible  by  studying  the 
effects  produced  by  compression  of  the  eye  to  obtain  on  the  uveal 
circulation  notes  similar  to  those  obtained  on  the  retinal  circulation. 

Sometimes,  particularly  in  extreme  myopia,  it  is  possible  to  per- 
ceive through  the  retina  the  choroidal  vessels;  but  we  can  but  ill 
distinguish  the  arteries  from  the  veins  and  on  the  other  hand  these 
vessels  never  show,  except  in  certain  exceptional  cases,  either  spon- 
taneous or  forced  pulsations.  When  considerable  pressure  is  applied, 
it  is  even  difficult  to  tell  at  what  precise  moment  they  are  emptied, 
and,  even  if  we  did  know  it,  this  would  have  little  value  since  we  can- 
not distinguish  the  small  arteries  from  the  small  veins. 

Consequently,  the  direct  examination  and  measuring  of  the  arterial 
pressure  in  the  choroidal  vessels  is  not  yet  possible. 

In  a  recent  work  G.  Leplat  has  shown  that  it  was  possible  under 
certain  favorable  conditions  to  study  "de  visu"  the  blood-pressure 
in  the  arteries  of  the  dog's  iris  by  making  use  of  the  process  we  have 
described.  The  importance  of  this  fact  is  truly  considerable;  this 
process  enables  us  to  acquire  for  the  first  time  some  ideas  on  the 
circulation  of  the  uvea  of  which  the  iris  is  the  sole  portion  which  is 
clearly  visible. 

In  man,  unfortunately,  the  iris  circulation,  like  the  choroidal  cir- 
culation, does  not  lend  itself  to  these  investigations,  and,  however 
great  was  our  desire,  we  were  unable  (even  with  the  magnification  of 
Czapskc's  loupe)  to  observe  any  iris  pulsation.  It  may  be  that  we 
should  see  in  this  fact  a  confirmation  of  Thomson  Henderson's  opinion 
that  the  arterial  circle  of  the  iris  in  man  is  in  reality  a  venous  circle. 

The  dog,  which  G.  Leplat  used  for  his  researches,  possesses  in  the 
periphery  of  the  iris,  particularly  on  the  side  toward  the  nose,  verit- 
able arterial  trunks  of  which  the  beatings  can  be  seen  with  a  magni- 
fying glass  of  low  power  or  even  under  good  conditions  of  lighting, 
with  the  naked  eye.  The  observation  of  the  pulsatile  arterial  reac- 


440  A.  MAGITOT  AND  P.  BAILLIART 

tions  is  thus  very  easy  and  enables  us  to  study,  as  our  Belgian  col- 
league has  done  so  well,  the  pressure  in  the  vessels  of  the  iris.  On 
our  side  we  have  undertaken  a  series  of  researches  for  the  purpose  of 
studying  comparatively  the  iris  circulation  and  the  retinal  circulation ; 
and  we  have  made  use  of  the  cat.  The  dog,  which  is  a  good  subject 
for  the  vessels  of  the  iris,  appeared  to  us  to  be  of  no  service  for  the 
study  of  the  vessels  of  the  retina;  for  its  central  vessels  when  they 
reach  the  disc  are  already  divided  into  fine  branches  surrounded  by 
neuroglia  tissue.  This  disposition  does  not  allow  the  beating  to 
attain  the  amplitude  desirable. 

The  retinal  vessels  of  the  cat,  apart  from  their  being  disposed  on 
the  periphery  and  not  in  the  center  of  the  disc,  and  their  ciliary 
origin,  resemble  on  the  contrary  fairly  exactly  the  vessels  of  the 
human  retina.  At  the  limit  of  the  dark  gray  disc  we  see  three  or 
four  arteries  each  with  a  vein  running  by  its  side.  The  artificial 
beats  which  we  provoke  must  always  be  sought  for  in  the  immediate 
circumference  of  the  disc.  They  are,  moreover,  very  easy  to  observe ; 
when  the  appropriate  pressure  is  applied  to  the  eyeball,  three  or  four 
small  arteries  can  be  seen  beating  simultaneously. 

The  vessels  of  the  iris  are  per  contra  rather  less  easy  to  observe 
than  those  of  the  dog.  In  order  to  see  them  well,  it  is  necessary  to 
make  use  of  Czapskc's  magnifying  glass,  and  to  examine  the  nasal 
extremity  of  the  horizontal  meridian;  a  voluminous  vein  (particularly 
if  one  looks  very  closely  at  the  root  of  the  iris,  before  its  bifurcation) 
will  be  seen  lifting  up  the  trabecular  tissue ;  at  this  spot  we  recognize 
the  existence  of  spontaneous  arterial  movements  which  pressure 
on  the  eyeball  exaggerates  and  transforms  into  veritable  pulsations 
and  finally  suppresses  completely.  If  the  retinal  pulsations  of  the 
cat  are  always  easy  to  see,  it  must  be  added  that  the  pulsations  of  the 
vessels  of  the  iris  are  sometimes  less  so. 

The  comparative  study  of  these  two  pulsatile  phenomena  has 
enabled  us  to  remark  that  in  the  eye  of  the  cat  the  pressure  in  the 
arteries  of  the  iris  and  of  the  retina  is  practically  the  same;  if  in  the 
average  case  it  has  been  necessary  to  apply  somewhat  stronger  pres- 
sures to  study  the  pulsation  in  the  iris  than  in  the  retina,  this  is  due, 
no  doubt,  on  the  one  hand  to  the  greater  difficulty  of  observation  in 
the  iris.  We  can  give  as  an  average  in  the  cat  for  the  arteries  of  the 
iris  and  the  retina  45  to  100  mm.  Hg,  which  figures  are  slightly  higher 
than  those  in  man. 


Blood-Pressure  in  the  Vessels  of  the  Eye  441 

These  experiments  on  animals  have  led  us  to  recognize  (which  we 
consider  to  be  quite  probable)  that  the  systems  of  blood-vessels  of 
the  retina  and  the  uvea,  so  similar  to  each  other  in  many  ways,  have 
in  their  normal  state  an  identical  working  pressure. 

We  have  since  had  fresh  confirmation  of  this  in  a  work  of  Vossius. 
This  author  had  occasion  to  examine  with  the  corneal  microscope  a 
filament  of  an  iris  in  a  persistent  pupillary  membrane.  On  applying 
dynamometric  pressure  to  the  eyeball  he  noted  that  circulation  was 
arrested  when  the  ocular  tension  reached  70  mm.  Hg.  This  figure 
(70  mm.  Hg)  is  also  that  which  we  found  for  the  normal  systolic 
pressure. 

The  study  of  the  effects  of  graduated  and  known  pressures  on  the 
eyeball  has  also  led  us  to  other  results.  We  have  been  able  to  ob- 
serve a  constant  phenomenon  which  can  be  formulated  as  follows : 

1.  From  an  initial  tension  of  15  mm.  there  exists  always  a  lowering 
of  the  ocular  tension  after  each  application  of  the  tonometer,  how- 
ever correctly  the  application  be  made.     Example:   take  an  eyeball 
of  which  the  tension  is  20  mm.  Hg;  submit  it  for  a  duration  of  three 
seconds  to  a  pressure  of  30  gram.     We  shall  find  immediately  after 
that  the  ophthalmotonus  is  no  longer  20  mm.  Hg,  but  only  15  mm. 

2.  This  phenomenon  no  longer  exists  when  the  same  pressures  are 
applied  to  eyeballs  possessing  only  a  tonus  of  10  to  12  mm.  Hg. 

3.  This  phenomenon  is  exaggerated  when  the  pressure  is  applied 
to  eyeballs  in  which  the  tension  has  been  raised  artificially  (in  our 
experiments  by  means  of  subconjunctival  injections  of  hypertonic 
serum).  , 

These  modifications  of  the  ocular  tonus  under  the  influence  of  slight 
pressures  applied  to  the  eyeball  had  already  been  noted  in  tonometric 
experimentation.  This  observation  had  already  been  made  clinically  in 
1911  by  Polak  Van  Gelder.  Using  Schiotz's  tonometer,  he  remarked 
that  in  normal  individuals  the  repeated  applications  of  this  instru- 
ment at  intervals  of  3  or  5  seconds  always  furnished  figures  lower 
than  the  first  ones.  If  we  translate  into  grams  the  pressure  exerted 
on  the  eyeball  by  the  tonometer  loaded  with  these  weights  of  5  or  of  7 
grams,  we  see  that  it  varies  from  21  to  25  grams.  In  Polak  Van 
Gelder's  tables  we  note  that  the  difference  between  the  ocular  tensions 
before  and  after  this  tonometric  pressure  is  about  10  mm.  Hg. 

This  fact  is  also  quite  clear  when  dynamometric  pressures  are 
applied  to  the  eyeball  in  order  to  measure  the  arterial  retinal  pressure. 


442  A.  MAGITOT  AND  P.  BAILLIART 

If,  when  by  means  of  a  given  pressure  we  have  managed  to  efface  the 
last  arterial  pulsation,  this  pressure  is  maintained  for  a  few  seconds, 
it  will  be  seen  that  the  arterial  pulsation  reappears  very  rapidly;  to 
suppress  it,  greater  pressure  must  be  applied;  if  this  pressure  is  main- 
tained the  pulsations  reappear.  Thus  the  ocular  tension  diminishes 
immediately  and  constantly  under  the  influence  of  dynamometric 
pressure.  This  fact  must  be  noted  as  it  explains  why  beginners,  who 
proceed  by  feeling  their  way,  always  find  very  high  figures  in  their 
attempts  to  determine  the  arterial  retinal  pressure. 

This  lowering  of  tension  under  the  influence  of  pressure  is,  more- 
over, very  transitory :  to  the  depression  there  succeeds  even  a  slight 
ulterior  elevation  which  lasts  a  very  short  time. 

How  can  we  explain  this  diminution  of  the  ocular  tension  under 
the  influence  of  ocular  pressure?  Evidently  by  the  issuing  of  a  part 
of  its  liquid  contents.  The  supporters  of  the  continuous  stream  of 
the  aqueous  humor  explain  it  by  a  more  active  filtration  of  this 
liquid  which  is  driven  out  of  the  eyeball  by  the  mechanical  effect  of 
the  compression.  For  our  part,  we  believe  that  the  question  is  not 
so  simple.  Remembering  the  modifications  of  the  ocular  tonus 
under  all  the  influences  which  can  act  upon  the  circulatory  system  of 
the  choroid,  the  fall  of  the  ophthalmotonus  after  ligature  of  the 
ciliary  arteries  or  of  the  carotid,  after  stimulation  of  the  "sympa- 
thetic," its  rise  which  follows  inhalation  of  amylis  nitris,  after  division 
of  the  sympathetic,  we  remain  convinced  that  the  compression  of  the 
eyeball  acts  by  emptying  the  choroidal  system,  and  that  this  mechani- 
cal expansion  of  the  external  coat  of  the  eye  brings  about  the  fall  of 
the  ocular  tonus,  which  rises  again  when  little  by  little  the  blood  fills 
once  more  the  exceedingly  rich  vascular  system  of  the  uvea. 


PLASTIC  OPERATIONS  ABOUT  THE  EYE 

SUGGESTIONS  FOR  SEVERAL  IMPORTANT  CONDITIONS 

DR.  JOHN  M.  WHEELER 

New  York  City 

In  considering  the  subject  of  plastic  surgery  of  the  structures  about 
the  eye,  I  shall  limit  myself  to  some  of  the  more  important  features 
of  operations  which  have  been  developed  in  my  experience,  while 
attempting  to  determine  the  best  methods  of  correcting  deformities 
in  the  eye  region.  In  my  opinion  surgery  of  the  eyelids,  eyebrows  and 
orbital  region  should  be  performed  by  ophthalmologists,  and  not  by 
those  who  have  no  special  knowledge  of  surgery  of  the  eye  region. 
General  surgeons  are  uninformed  on  the  peculiar  features  and  require- 
ments here,  and  they  are  not  trained  in  the  refinements  essential  to 
success  in  plastic  eye  surgery. 

Plastic  eye  work  enriches  the  field  of  ophthalmic  surgery  and 
broadens  the  scope  of  the  ophthalmologist  without  interfering  with  the 
special  skill  which  he  must  develop  in  order  to  perform  successfully 
the  important  operations  on  the  eyeball  proper;  and  certainly  nothing 
should  be  allowed  to  detract  from  the  high  importance  of  the  skill  and 
refinement  and  judgment  called  for  in  handling  such  conditions  as 
cataract  and  glaucoma. 

In  studying  and  applying  methods  for  handling  cases  of  deformity 
about  the  eyes  I  have  always  had  in  mind  these  two  things.  First,  to 
avoid  adding  new  deformities  through  my  surgery.  Second,  to  develop 
procedures  which  are  as  simple  as  possible  and  which  are  appropriate 
for  general  adoption  by  trained  eye  surgeons. 

In  order  to  make  satisfactory  comparisons  of  the  relative  merits  of 
different  sorts  of  grafts  in  corrective,  surface  work  of  the  eyelids  and 
thereabouts,  I  have  used  different  types  of  grafts  and  different  meth- 
ods on  the  same  patient.  For  instance,  one  patient  who  needed  more 
than  one  correction  received  a  true  skin  flap  from  the  inner  aspect  of 
the  arm,  a  free  graft  of  true  skin  from  one  temple,  and  a  pedunculated 
flap  from  the  other  temple.  Another  received  epidermic  grafts  from 
the  thigh,  and  true  skin  from  an  upper  lid.  Another,  a  pedunculated 

443 


444  JOHN  M.  WHEELER 

flap  from  the  temple,  a  free  graft  from  the  arm  and  a  free  graft  from 
the  upper  eyelid,  and  so  on.  Thus,  by  making  different  sorts  of  com- 
binations, it  was  possible  to  study  results  in  an  unprejudiced  and  con- 
vincing way. 

ClCATRICIAL  ECTROPION 

SIMPLE  CICATRICIAL  ECTROPION. — This  is  the  ordinary  variety  that 
we  have  to  deal  with  most  commonly,  in  which  the  lower  eyelid,  or 
more  rarely  the  upper,  is  pulled  away  from  the  globe  by  scar  tissue, 
but  in  which  the  lids  otherwise  have  suffered  little.  In  most  cases  of 
traumatism  resulting  in  ectropion,  only  a  single  eyelid  is  involved,  and 
the  lower  lid  suffers  more  frequently  than  the  upper.  For  simple 
ectropion,  by  far  the  most  satisfactory  correction  can  be  obtained  by 
means  of  an  inlay  of  true  skin  from  one  of  the  upper  lids.  It  is  sur- 
prising how  seldom  one  or  the  other  upper  lid  will  fail  to  provide 
ample  skin  for  grafting.  So  for  most  cases  of  cicatricial  ectropion  I 
employ  detached  upper  lid  dermis.  A  match  in  appearance  is  assured 
without  the  creation  of  an  additional  deformity.  There  need  be  no 
fear  for  the  upper  lid  on  account  of  removal  of  the  skin.  A  fusiform 
flap  of  true  skin  50  mm.  long  and  25  mm.  wide  can  be  taken  safely 
from  most  any  normal  upper  eyelid,  and  some  could  furnish  much 
greater  width.  In  one  young  adult  I  have  taken,  at  intervals  of  a  few 
months,  three  separate  grafts  from  the  left  upper  eyelid  without 
lagophthalmos  or  appreciable  deformity.  The  stretching  of  this  skin 
tissue  and  readjustment  to  the  normal  appearance  is  remarkable.  A 
description  of  this  operation  was  published  in  1921. : 

Technic  of  Operation. — The  primary  incision  should  be  parallel  to 
the  distorted  lid  margin.  Cicatricial  tissue  should  be  so  thoroughly 
and  painstakingly  removed  that  there  will  be  no  tendency  of  the  lid  to 
evert,  and  scarcely  more  than  normal  resistance  to  upward  traction  at 
the  lid  margin  (Fig.  1).  In  making  the  preparatory  dissection,  the 
tissues  should  not  be  handled  roughly.  Artery  clamps  should  not  be 
used  unnecessarily  and  no  ligatures  should  be  used  on  bleeding  vessels. 

Either  two  or  three  firm  adhesions  between  the  upper  and  lower  lids 
are  made  by  dissecting  off  epithelium  at  corresponding  positions  on 
the  upper  and  lower  lid  margins,  and  carrying  mattress  sutures 
through  the  little  raw  surfaces.  They  are  passed  through  small  plates 
of  rubber  (cut  from  sterile  rubber  tubing)  overlying  the  skin  of  both 
upper  and  lower  lids  near  their  margins  (Fig.  2).  These  sutures  are 
1  Jour.  Amer.  Med.  Assn.,  July  19. 


Plastic  Operations  About  the  Eye 


445 


tied  snugly  to  insure  firm  apposition  of  the  opposing  raw  surfaces. 
Union  of  these  raw  surfaces  causes  the  formation  of  adhesions  for  the 
support  of  the  lower  lid.  Later,  these  adhesions  stretch  somewhat  and 
are  covered  with  a  growth  of  epithelium.  This  stretching  allows  of 
very  slight  separation  of  the  lids,  so  that  the  patient  can  see  through 
the  palpebral  fissure,  a  thing  to  be  encouraged,  as  elevation  of  the 
upper  lid  stretches  the  lower.  With  this  in  view,  it  is  well  to  avoid 
making  an  adhesion  directly  in  front  of  the  pupil. 

Removal  of  the  True  Skin  Graft  from  the  Upper  Lid. — This  is  very 


Fig.  1. — Simple  cicatricial  ectropion 
of  left  lower  eyelid.  Dissection  in 
lower  lid  completed  and  graft  outlined 
in  upper  lid. 


Fig.  2. — True  skin  graft  from  upper  lid 
sutured  in  position  in  lower  lid. 


simple  as  compared  with  the  dissection  of  a  dermic  flap  from  the  arm, 
thigh  or  elsewhere.  Almost  no  allowance  need  be  made  for  contrac- 
tion. In  fact,  a  graft  exactly  the  dimensions  of  the  raw  surface  to  be 
covered  will  answer.  This  graft  can  be  taken  from  either  upper  lid, 
but  ordinarily  would  be  taken  from  the  ipsolateral  lid.  In  removing 
the  graft,  I  do  not  use  a  grasping  forceps  of  any  kind  for  fear  of  bruis- 
ing the  tissue  cells.  Outlining  incisions  are  made  through  the  dermis 
of  the  upper  lid.  A  fusiform  or  semilunar  shaped  design  is  convenient 
to  take.  A  cataract  knife  is  slid  under  the  skin  from  the  lower  incision 


446  JOHN  M.  WHEELER 

to  the  upper.  The  knife  is  carried  by  careful  sliding  motions  nearly  to 
one  end  of  the  graft.  Then  it  is  turned  about  and  carried  to  the  other 
end,  freeing  it.  The  piece  of  skin  is  picked  up  with  the  fingers  and 
set  free. 

By  placing  the  graft,  epithelial  surface  downward,  on  a  pad  wet 
with  warm  (body  temperature)  normal  salt  solution,  any  fragments  of 
subcutaneous  tissue  can  be  quickly  snipped  off  with  the  scissors.  This 
is  not  a  tiresome  process  as  it  is  in  the  case  of  an  arm  graft.  Fine  silk 
sutures  (No.  1  twisted)  impregnated  with  paraffin  are  used  to  stitch 
the  graft  in  position.  The  ends  should  be  secured  first,  and  then  the 
margins  should  have  as  many  sutures  as  may  be  needed  to  hold  them 
in  place.  No  undermining  is  necessary  in  order  to  bring  the  wound 
edges  together  on  the  upper  lid.  The  raw  surface  is  easily  closed  over 
by  fine  silk  sutures,  and  there  need  be  no  fear  of  subsequent  opening  of 
this  wound. 

Dressing. — The  graft  should  be  covered  with  rubber  tissue,  having 
the  slightest  smear  of  sterile  petrolatum.  I  prefer  to  put  the  tissue  on 
in  two  layers  with  the  grains  running  at  right  angles,  to  guard  against 
the  possibility  of  perforations  through  separation  of  the  tissue  fibers. 
The  rubber  tissue  will  prevent  the  skin  graft  from  getting  dry.  If  a 
covering  other  than  rubber  tissue  is  chosen,  it  should  be  of  smooth  sur- 
face, pliable  and  without  perforations.  Over  the  tissue,  gauze  fluff  is 
packed  and  secured  firmly  by  adhesive  plaster,  and  then  by  pressure 
bandage,  which  in  turn  should  be  secured  by  adhesive  plaster.  It  is 
well  to  put  a  separate  dressing  over  the  other  eye,  to  be  left  for  two  or 
three  days,  and  then  to  be  cut  down  without  disturbing  the  main 
dressing  and  bandage.  This  should  be  left  for  six  days,  at  the  end  of 
which  time  it  is  removed  with  the  utmost  care,  and  the  graft  pains- 
takingly cleansed  with  damp  (not  wet)  boric  acid  sponges,  and  all 
sutures  taken  out.  At  the  first  dressing  the  grafted  skin  will  appear 
pink,  not  anemic  like  a  graft  from  the  arm.  The  outlines  of  the 
beautiful  inlay  are  hardly  seen  even  at  the  first  dressing.  Rubber 
tissue,  gauze  dressing  and  bandage,  changed  every  two  days,  are  con- 
tinued for  another  week ;  then  dressing  is  no  longer  necessary,  and  the 
graft  is  kept  smeared  with  a  little  sterile  petrolatum. 

About  three  weeks  after  operation  it  is  well  to  start  massage  with 
petrolatum.  This  is  kept  up  daily  for  several  weeks.  The  adhesions 
between  the  lids  should  remain  for  at  least  three  months.  They  should 
be  left  until  all  tendency  to  malposition  of  the  lid  has  passed.  They 
are  then  cut  with  the  scissors  and  no  deformity  results  from  them. 


Plastic  Operations  About  the  Eye 


447 


SEVERE  ECTROPION  DUE  TO  BURNS. — Occasionally  we  have  to  deal 
with  extreme  ectropion  of  all  the  lids  associated  with  facial  burns,  and 
large  loss  of  the  cilia  and  brows.  Usually  the  outer  canthus  is  pulled 
well  down  out  of  position  and  there  may  be  epicanthal  folds.  In  such 
cases  it  may  not  be  feasible  to  implant  true  skin  grafts,  and  it  is  con- 
venient to  resort  to  epidermis.  Fortunately,  in  these  bad  burn  cases 
epidermis  matches  the  scarred  tissue  of  the  face  about  as  well  as  true 
skin  from  a  distant  part,  and  it  is  possible  to  cover  as  large  areas  as 
necessary. 

Operation. — Usually  general  anesthesia  is  called  for  in  the  severe 


Fig.  3.— Operation  for  severe  cicatricial  ectropion.  Dissection  for  replace- 
ment of  eyelids  completed.  Upper  lid  held  by  forceps  to  show  areas  denuded  in 
margin  for  intermarginal  adhesions. 

cases.  After  the  preparatory  dissection  of  the  eyelids,  there  is  a  large 
exposure  for  the  reception  of  the  epidermic  graft.  Both  upper  and 
lower  eyelids  are  repaired  at  the  same  sitting.  Fig.  3  shows  at  the  lid 
margins  the  little  areas  which  have  been  denuded  of  epithelium  in  prep- 
aration for  the  adhesions  to  hold  the  lid  margins  together.  These 
adhesions  are  important  in  the  correction  of  all  ectropion  cases,  but 
especially  so  in  the  severe  cases  where  large  denuded  areas  have  to  be 
covered.  After  passing  the  sutures  to  secure  apposition  of  the  raw 
areas  of  the  margins,  a  single  large  piece  of  epidermis  from  the  outer 


448 


JOHN  M.  WHEELER 


aspect  of  the  thigh  is  placed  over  the  lids,  overlapping  the  margins  of 
the  denuded  areas  all  around.  For  this  purpose  a  graft  with  an  area  of 
9  to  12  square  inches  may  be  needed.  (It  is  taken  as  for  restoration  of 
the  socket.)  No  sutures  are  used  but  the  pressure  of  a  secure  dressing 
and  bandage  are  relied  on  to  hold  the  graft  firmly  in  place.  After 
placing  the  skin  in  position  a  slit  should  be  made  in  it  just  in  front  of 
the  palpebral  fissure  to  provide  for  drainage  of  conjunctival  secretion. 
A  slit  is  also  made  in  the  rubber  tissue  which  is  placed  over  the  graft 
(Fig.  4).  Dressing  and  after-care  are  the  same  as  described  for  the 


Fig.  4. — Eyelids  in  position  for  reception  of  epidermic  graft.  Sutures  have 
been  passed  through  denuded  areas  in  lid  margins  and  tied  over  little  plates  of 
rubber.  A  single  epidermic  graft  has  been  placed  over  denuded  areas  in  lids.  Slit 
in  graft  in  front  of  palpebral  fissure. 

dermic  graft.  In  cases  with  bad  facial  scars,  especially  if  there  is  a 
tendency  to  keloid  formation,  it  may  be  wise  to  leave  the  interpalpe- 
bral  adhesions  for  as  long  as  a  year,  and  it  may  be  necessary  to  graft  a 
second  time  if  late  contraction  of  facial  scar  tissue  pulls  the  palpebral 
fissure  out  of  place.  When  the  work  is  completed  the  external  canthus 
should  be  on  a  level  with  the  internal.  Let  me  suggest  an  important 
precaution  in  regard  to  the  preparatory  dissection  of  the  lids.  It  is 
permissible  for  the  denuded  areas  of  the  upper  and  lower  lids  to  com- 
municate at  the  temporal  side  of  the  palpebral  fissure,  but  it  is  a  mis- 


Plastic  Operations  About  the  Eye  449 

take  for  the  surgeon  to  establish  a  communication  at  the  nasal  side,  as 
a  fold  will  form  during  the  healing  process  and  make  a  cicatricial 
epicanthus.  This  gives  a  cosmetic  blemish  for  which  we  have  no  sat- 
isfactory operation. 

If  the  brows  have  not  been  destroyed,  it  may  be  worth  while  to 
graft  from  them  for  cilia  lines,  before  the  interpalpebral  adhesions  are 
severed.  Otherwise  artificial  lashes  may  be  resorted  to. 

An  important  question  which  is  apt  to  confront  us  in  connection 
with  the  severe  burn  cases,  is  whether  to  operate  early,  before  the 
facial  burns  are  healed,  or  to  wait  until  cicatricial  contraction  has 
progressed.  I  should  operate  as  soon  as  the  physical  condition  of  the 
patient  will  allow,  even  if  it  means  operating  again  later  on.  This 
judgment  is  based  on  the  importance  of  protection  for  the  cornea  by 
the  lids,  which  will  be  held  by  the  adhesions  between  their  margins. 

In  ectropion  I  now  find  use  for  pedunculated  flaps  only  in  those  cases 
where  there  has  been  loss  of  bony  tissue  with  a  consequent  depression 
to  be  filled  in.  Here  thickness  is  called  for.  A  flap  can  be  turned  down 
from  the  temple  or  forehead  by  the  well-known  methods  of  procedure, 
and  the  thickness  can  be  gauged  to  suit  the  needs  of  the  case;  that  is, 
where  the  depression  is  greatest  the  flap  can  be  made  thickest. 

RESTORATION  OF  BROW 

Dislike  for  making  new  deformities  and  desire  for  simplicity  have 
kept  me  from  turning  pedicled  flaps  from  the  hairy  scalp  or  elsewhere 
in  attempts  to  bring  about  the  formation  of  new  brows.  I  have  used 
only  free  grafts.  Loss  of  the  brow  is  usually  not  complete,  and  rather 
satisfactory  patch  work  can  be  done  in  some  cases  by  taking  from  one 
part  of  the  brow  to  fill  out  another,  or  by  taking  from  one  brow  to 
help  out  its  fellow. 

If  one  brow  is  intact  and  the  other  partially  or  wholly  destroyed,  the 
intact  brow  can  be  divided  longitudinally  and  the  lower  part  trans- 
planted as  a  detached  graft  to  the  other  side.  In  order  to  have  the 
hairs  of  the  transplanted  graft  slant  toward  the  temple,  it  must  be 
turned  upside  down.  This  splitting  procedure  is  not  altogether  sat- 
isfactory, as  the  resulting  brows  are  usually  noticeably  narrow,  and 
the  direction  of  the  hairs  in  the  graft  is  not  ideal.  Moreover,  some  of 
the  follicles  are  liable  to  be  destroyed  in  the  process.  The  reason  for 
selecting  the  lower  part  of  the  brow  for  transplantation  is  that  the  skin 
tissue  is  much  thinner  below  than  elsewhere  in  the  brow  and  the  hair- 
follicles  are  shorter.  This  is  true  to  such  an  extent  that  a  graft  includ- 
29 


450  JOHN  M.  WHEELER 

ing  the  hairs  of  the  lower  part  of  the  brow  is  wedge-shaped  on  cross- 
section,  with  the  apex  of  the  wedge  downward. 

Possibly  the  most  satisfactory  way  of  grafting  for  an  entire  brow  or 
a  large  part  of  one  is  to  remove  a  flap  of  scalp  from  the  occipital  region 
of  the  desired  size  and  shape  and  place  it  in  position.  The  hair-follicles 
are  usually  closely  placed  in  the  middle  of  the  occipital  region,  and 
they  are  well  slanted.  Moreover,  no  visible  scar  results.  One  objec- 
tion to  the  scalp  graft  is  that  the  color  of  the  hair  may  not  accurately 
match  the  color  of  the  fellow  brow.  Another  objection  is  that  a  part 
of  the  graft  may  be  lost.  The  reason  for  this  is  that  the  scalp  tissue  is 
thick,  and  the  graft  cannot  be  made  thin  without  injuring  the  hair- 
follicles,  which  are  long  enough  to  go  entirely  through  the  scalp  skin. 
One  cannot  transplant  thick  detached  grafts  with  confidence,  as  is 
possible  with  thin  skin  grafts. 

A  few  suggestions  as  to  the  technic  of  implanting  the  scalp  graft 
may  be  offered.  Novocain  infiltration  anesthesia  is  satisfactory.  In 
preparing  the  bed  for  the  reception  of  the  graft,  a  curved  incision 
through  the  thick  supraorbital  skin  is  made  in  the  proper  position  and 
of  the  proper  length.  Usually  the  skin  is  on  the  stretch  on  account  of 
the  presence  of  scar  tissue  and  the  wound  gaps  in  admirable  fashion, 
so  that  it  may  not  be  necessary  to  remove  any  skin  in  order  to  get  a 
good  exposure  of  the  subcutaneous  tissue.  The  thick  scalp  graft  will 
not  set  into  the  depression  made  by  the  skin  incision,  but  will  project 
and  its  life  will  be  endangered.  So  a  longitudinal  incision  should  be 
carried  along  the  middle  of  the  exposed  area  down  to  the  periosteum 
or  near  it.  Usually  it  is  possible  to  avoid  the  supraorbital  nerve  and 
vessels.  Regeneration  of  the  nerve  can  be  expected,  however,  if  it  is 
cut. 

In  preparation  for  removal  of  the  graft  the  scalp  area  should  be 
shaved,  cleansed  with  alcohol  and  ether,  and  painted  with  iodin. 
The  graft  needed  is  usually  rather  long  and  pointed.  The  curved  in- 
cisions for  its  removal  should  slant  toward  each  other,  so  that  a  cross 
section  of  the  graft  is  like  a  truncated  wedge  with  base  at  the  surface. 
This  will  fit  deeply  into  the  depressed  exposed  area  in  the  brow  region, 
as  the  sides  of  this  depression  will  be  "banked."  In  taking  a  scalp 
flap  there  is  inevitable  destruction  of  some  of  the  hair-follicles,  but 
with  a  complete  take  or  nearly  that  a  good  mat  of  hair  should  result. 
The  graft  should  be  sutured  in  place  and  firm  pressure  applied.  The 
resistance  offered  by  the  skull  is  a  valuable  help  to  the  pressure  dress- 
ing in  getting  firm  contact  between  raw  surfaces.  "Tulle  Gras,"  as 


Plastic  Operations  About  the  Eye 


451 


recommended  by  Morax  and  others,  is  suitable  to  lay  over  the  graft 
before  putting  on  the  gauze  dressing  and  pressure  bandage.  A  few 
layers  of  vaselin  gauze  will  answer  equally  well  as  a  covering  for  the 
graft. 

RESTORATION  OF  THE  CILIA  LINE 

There  are  several  types  of  cases  calling  for  restoration  of  the  eye- 
lash line.    I  should  like  to  give  four  suggestive  ideas: 

1.  In  cases  such  as  were  mentioned  under  the  head  of  severe 
ectropion,  usually  extensive  loss  of  eyelashes  results.    Occasionally  in 


Fig.  5. — Loss  of  eyelash  line.  Eye- 
lids held  together  by  adhesions.  Eye- 
ball intact.  Bed  prepared  for  graft  at 
margin  of  upper  lid.  Hairy  graft  from 
brow  about  to  be  turned  and  placed  at 
lid  margin. 


Fig.  6. — Hairy  graft  from  brow  su- 
tured in  position  at  lid  margin.  Brow 
wound  closed  by  sutures. 


extreme  ectropion  the  upper  lid  margin  is  found  in  the  brow,  and  it  is 
possible  to  make  the  releasing  incision  in  the  lower  part  of  the  brow 
instead  of  below  it,  and  so  carry  down  a  hair  line  at  the  time  of  the 
dissection  made  in  preparation  for  the  epidermic  graft.  This  idea  is 
decidedly  worth  bearing  in  mind. 

2.  Let  us  suppose  a  case  of  severe  ectropion  in  which  the  lid  margin 
is  not  actually  in  the  brow  and  so  the  scheme  just  mentioned  is  not 
feasible,  and  let  us  suppose  epidermic  grafts  have  covered  both  upper 
and  lower  lids,  and  the  lids  are  held  together  by  adhesions  in  front  of 


452 


JOHN  M.  WHEELER 


the  eyeball.  Figs.  5  and  6  indicate  the  scheme  to  be  recommended. 
The  hairs  should  be  taken  as  largely  as  possible  from  the  nasal  end 
of  the  inferior  border,  as  here  they  are  more  numerous  than  at  the 
temporal  end  and  stand  out  in  better  direction.  The  idea  in  turning 
the  graft  upside  down  is  to  bring  the  hair  line  as  near  the  lid  border  as 


Vv 


\ 


Fig.  7. — Loss  of  part  of  upper  lid  margin  and  eyelashes.  Eyeball  has  been 
removed.  Sutures  introduced  to  unroll  skin  at  injured  lid  margin  and  attach  it 
to  orbital  contents. 


Fig.  8. — Graft  shown  both  before  complete  detachment  from  brow  and  after 
suturing  in  position  at  lid  margin. 

possible.  A  few  weeks  after  the  interpalpebral  adhesions  have  been 
cut  the  lid  margin  should  be  trimmed  off  evenly  close  to  the  new  cilia 
line. 

3.  In  another  type  the  eye  may  have  been  lost  and  a  part  of  the  lid 
margin  with  the  cilia  may  have  been  destroyed.     In  such  a  case  a 


Plastic  Operations  About  the  Eye  453 

curved  incision  may  be  made  near  the  injured  margin  and  the  skin 
below  it  dissected  up.  Then  this  skin  is  rolled  back  and  tied  down  to 
the  fundus  of  the  socket  with  silk  sutures,  as  shown  in  Fig.  7.  Then  a 
graft  from  the  nasal  end  of  the  lower  margin  of  the  brow  is  placed  so 
that  the  hairs  will  line  up  with  the  remaining  cilia  as  accurately  as 
possible  (Fig.  8).  It  will  be  seen  that  the  hairs  of  the  graft  really  over- 
lie the  unrolled  skin  and  so  fall  in  line  with  the  cilia.  A  little  trimming 
of  the  margin  of  the  lid  may  have  to  be  done  later. 

4.  Another  possibility  should  be  borne  in  mind.  When  skin  of  the 
upper  eyelid  is  used  for  an  ectropion  of  a  fellow  upper  lid  or  a  lower 
lid,  it  is  feasible  to  carry  the  upper  graft  incision  into  the  lower  part 
of  the  brow  and  so  carry  with  the  graft  a  line  of  hairs  to  be  placed  for 
cilia.  The  graft  below  the  cilia  line  may  be  made  as  large  as  desired. 
If  this  idea  is  used,  in  order  to  bring  the  hair  line  to  the  lid  margin, 
the  graft  is  carried  directly  to  the  denuded  area,  without  turning,  for 
the  lower  lid;  but  for  ectropion  of  the  upper  lid  the  detached  graft 
has  to  be  turned  upside  down. 

It  would  be  absurd  for  one  to  expect  a  perfect  line  of  eyelashes  to 
result  from  any  attempt  at  substitution,  but  patients  are  delighted 
with  the  imperfect  results  which  can  be  obtained  by  the  schemes 
suggested. 

NOTCH  AT  LID  MARGIN 

A  condition  which  we  have  to  deal  with  occasionally  is  a  deformity 
associated  with  laceration  of  the  tarsus,  manifesting  itself  in  angulation 
of  the  lid  margin  and  in  destruction  and  distortion  of  cilia  at  the  site  of 
injury.  This  may  be  associated  with  ectropion  or  other  deformity, 
but  should  be  recognized  as  an  entity.  In  a  paper  entitled  "War 
Injuries  of  the  Eyelids,"1  I  referred  to  a  method  of  handling  this  con- 
dition and  called  the  little  procedure  the  "  Halving  Operation."  The 
illustration  (Fig.  9)  gives  the  appearance  of  the  deformity  and  the 
scheme  of  correction. 

Operation. — The  little  mass  of  scar  formation  around  the  laceration 
of  the  tarsus  is  excised,  and  the  tarsal  flaps  are  cut  cleanly  across  to 
give  accurate  apposition.  Assuming  that  the  deformity  is  in  the  upper 
eyelid,  care  should  be  taken  to  excise  fully  as  much  tarsus  at  the  upper 
margin  as  at  the  lower  in  each  flap  of  the  tarsus.  This  is  important, 
and  even  a  slight  overcorrection  of  the  notch  can  be  obtained,  at  the 
surgeon's  discretion,  by  diverging  the  tarsal  incisions  from  the  lid  mar- 

1  Trans.  Amer.  Ophth.  Soc.,  1919. 


454 


JOHN  M.  WHEELER 


gin,  so  as  to  make  the  tarsal  flaps  slightly  shorter  above  than  below. 
The  skin  and  orbicularis  are  cut  so  as  to  make  a  flap  on  one  side,  and  a 
rectangular  area  of  tarsus  is  exposed  on  the  other.  If  necessary,  to 
prevent  tension  on  the  wound,  especially  if  the  eyeball  has  not  been 
removed,  a  canthotomy  should  be  performed,  and  the  branch  of  the 
external  canthal  ligament  should  be  severed  to  release  the  tarsus.  The 
little  tongue  of  skin  is  trimmed  enough  for  adjustment  and  a  small 
triangular  piece  of  skin  may  be  removed  above  to  avoid  puckering. 
The  conjunctiva  and  tarsal  flaps  are  first  sutured.  A  mattress  suture 
is  carried  through  the  flaps,  and  tied  after  passing  through  a  small 
rubber  plate  cut  from  sterile  tubing.  Sutures  are  introduced  to  give 
good  apposition  of  the  skin  flaps.  The  mattress  suture  should  be 


Fig.  9. — Scheme  for  correction  of  notch  of  eyelid. 

removed  in  two  or  three  days,  and  the  others  about  five  days  after 
operation. 

An  important  point  is  that  tarsal  wound  and  skin  wounds  should 
never  be  in  the  same  position,  but  should  be  placed  in  such  a  way  that 
there  is  overlapping.  Thus,  what  is  known  in  carpentry  as  halving  is 
accomplished,  and  union  is  assured,  even  if  there  is  a  little  sloughing 
of  the  skin.  Furthermore,  recurrence  of  the  notch  formation  is  pre- 
vented. After  healing  there  is  no  break  in  the  continuity  of  the  lid 
margin  or  in  the  row  of  eyelashes.  In  handling  notch  cases  different 
short-cut  procedures  have  been  tried,  but  the  " halving"  method  has 
been  the  only  satisfactory  one  in  my  hands. 

In  notch  cases  sometimes  it  is  necessary  to  dissect  out  bands  of  scar 
tissue  which  lead  from  the  tarsal  laceration  to  the  margin  of  the  orbit. 


Plastic  Operations  About  the  Eye 


455 


There  should  be  complete  release,  so  that  the  lid  margins  will  fall 
ea'sily  and  completely  together. 

TRAUMATIC  COLOBOMA  OF  LOWER  EYELID  NEAR  INNER  CANTHUS 
A  rather  common  injury  is  that  of  laceration  of  the  lower  eyelid 
through  the  canaliculus,  extending  downward  and  outward  more  or 
less  accurately  along  the  lower  orbital  margin.  Improper  primary 
healing  of  such  a  wound  results  in  a  coloboma  near  the  inner  canthus 
and  ectropion  of  the  lid  near  the  coloboma.  Complete  correction  of 
this  deformity  can  be  obtained  by  a  simple  manceuver.  Fig.  10  is 


Fig.  10. — Operation  for  correction  of  coloboma  of  lower  lid  near  inner  canthus. 
To  show  sutures  ready  to  tie  at  apex  of  flap. 


from  an  unpublished  series  of  drawings  and  is  an  attempt  to  show  the 
way  the  dissection  is  made  and  the  way  the  sutures  are  placed  to 
make  the  correction.  Scar  tissue  at  and  near  the  coloboma  is  dis- 
sected away.  An  incision  is  carried  from  the  coloboma  downward  and 
outward.  The  attachment  of  the  lower  lid  to  the  external  canthal 
ligament  is  severed,  and  if  necessary,  another  incision  is  carried  out- 
ward and  slightly  upward  from  the  outer  canthus.  The  flap  is  under- 
mined as  much  as  necessary  so  that  its  apex  can  easily  be  carried  to 
the  inner  canthus.  The  amount  of  dissection  necessary  will  depend 
upon  the  amount  of  tissue  loss  at  the  coloboma.  Sutures  are  placed 


456  JOHN  M.  WHEELER 

diagonally  along  the  incisions  in  such  a  way  as  to  advance  the  whole 
flap  and  have  as  little  pull  as  possible  for  the  sutures  at  the  apex  of  the 
flap  during  the  healing  process.  Of  greatest  importance  is  the  adjust- 
ment of  the  tissues  at  the  apex  of  the  flap.  The  small  amount  of  skin 
just  external  to  the  inner  canthus  is  carefully  and  completely  under- 
mined. The  skin  and  orbicularis  are  stripped  from  the  anterior  sur- 
face of  the  tarsus  so  as  to  expose  4  or  5  mm.  of  the  tarsus.  A  suture 
is  carried  through  the  exposed  tarsus,  and  then  it  is  carried  well  into 
the  internal  lateral  ligament  or  into  the  deep  fascial  tissue  behind  it  so 
as  to  get  a  firm  hold.  A  mattress  suture  mounted  with  two  needles  is 
carried  through  the  exposed  tarsus,  then  through  the  flap  of  skin 
which  has  been  dissected  up  near  the  inner  canthus  (Fig.  10).  When 
the  sutures  are  snugly  tied  the  apposition  will  be  secure  and  the  lid 
will  lie  well  back  against  the  globe  and  well  up  to  the  proper  level,  or 
even  high  enough  to  be  in  a  position  of  overcorrection.  Without  this 
careful  adjustment  and  definite  overlapping  of  raw  surfaces  one  can- 
not be  sure  of  complete  obliteration  of  the  deformity. 

RESTORATION  OF  OBLITERATED  SOCKET 

Many  suggestions  have  been  made  for  making  new  sockets  after 
obliteration,  and  many  disappointments  have  resulted  from  various 
sorts  of  procedures.  Without  entering  into  a  discussion  of  the  relative 
merits  of  the  different  operations  designed  for  socket  restoration,  let 
me  speak  briefly  of  the  method  which  I  have  adopted,  and  which  I  can 
recommend  with  confidence. 

Epidermis  has  been  chosen  as  the  most  satisfactory  tissue  for  lining 
the  cavity,  as  it  will  give  a  thin,  pliable  lining,  free  from  hairs  and  an 
excess  of  oily  secretion.  The  lateral  aspect  of  the  thigh  is  usually  the 
most  convenient  place  from  which  to  take  it.  No  elaborate  prepara- 
tion is  necessary.  The  part  from  which  the  epidermis  is  to  be  taken 
is  shaved  and  cleansed  with  alcohol  and  ether.  Then  with  a  long- 
bladed  knife  or  razor  with  a  keen  edge,  a  large  piece  of  epidermis  is 
taken.  For  taking  the  graft  I  am  now  using  the  Stille  (Norwegian) 
graft  knife,  and  an  interested  barber  gives  it  an  exquisitely  sharp  edge, 
without  which  it  is  impossible  to  get  a  large  graft  free  from  per- 
forations and  free  from  true  skin.  This  knife  has  a  long  blade,  and  is 
like  a  large  table  knife.  The  method  adopted  has  been  previously 
described  in  detail.1 

If  the  lid  margins  are  adherent,  they  are  separated  by  an  incision. 
1  Amer.  Jour.  Ophth.,  July,  1921. 


Plastic  Operations  About  the  Eye  457 

The  dissection  is  then  carried  out  in  such  a  way  as  to  separate  the  lids 
from  the  orbital  contents.  The  following  points  should  be  borne  in 
mind: 

1.  The  dissection  must  be  kept  superficial  so  that  in  front  of  the  dis- 
secting knife  or  scissors  there  is  only  lid  tissue,  i.  e.,  only  skin,  orbic- 
ularis,  the  thin  fascia  of  the  lid,  and  the  tarsus.    It  is  not  necessary 
to  save  the  tarso-orbital  fascia  with  the  lid.    Carrying  the  dissection 
back  into  the  orbital  tissue  is  probably  one  of  the  most  common  causes 
of  failure. 

2.  Not  only  the  superficial  plane  of  the  dissection,  but  the  extent 
and  limitation  of  the  dissection  are  of  importance.     Temporally  and 
below,  the  dissection  should  be  carried  well  to  the  orbital  margin  or 
even  1  mm.  or  2  mm.  beyond  it,  as  the  graft  must  adhere  to  the 
periosteum  of  the  anterior  aspect  of  the  orbital  margin.    On  the  nasal 
side  the  dissection  should  be  extended  to  the  anterior  crest  of  the 
lacrimal  groove  and  to  the  orbital  margin  above  it.      In  dissecting 
at  the  inner  canthus  the  caruncle  should  be  saved  if  it  has  not  been 
destroyed.    The  graft  will  adhere  to  the  posterior  surface  of  the  car- 
uncle and  give  it  a  permanent  lining.    In  the  division  of  the  tissues 
above,  the  dissection  should  be  carried  behind  the  orbital  rim  but  not 
necessarily  to  the  roof  of  the  orbit.    In  some  cases  the  levator  pal- 
pebrae  superior  is  can  be  saved. 

3.  In  preparing  the  bed  for  the  graft  all  cicatricial  and  granulation 
tissue  should  be  removed.    Excision  of  granulation  tissue  is  especially 
important  as  the  contraction  of  such  tissue  may  result  in  contraction 
of  the  socket.    Reduction  in  size  of  the  newly  made  socket  is  due  to 
contraction  of  the  underlying  tissue  rather  than  to  contraction  of  the 
skin  itself. 

4.  A  common  fault  which  manifests  itself  after  restoration  of  the 
socket  is  that  of  too  great  thickness  of  the  lid  margin.    This  deformity 
can  be  obviated  by  cutting  away  tarsus.    If  the  skin  graft  must  ex- 
tend completely  to  the  margin  of  the  eyelid,  the  tarsus  may  be  split 
and  thinned.    If  the  graft  is  to  extend  nearly  to  the  margin,  sufficient 
tarsal  plate  may  be  cut  away  so  that  the  graft  will  set  in  as  an  inlay 
In  any  case,  enough  tarsus  should  be  left  to  support  the  cilia,  but  not 
necessarily  any  more.    A  form  should  then  be  molded  to  fit  the  cavity. 
Dental  impression  compound  is  ideal  for  this  purpose.    Ordinarily  for 
full  restoration  of  the  socket,  the  dimensions  are  approximately  as 
follows:  length  40  mm.  to  45  mm.,  width  30  mm.,  thickness  5  mm. 

The  ideal  graft  for  socket  restoration  is  one  without  perforations 


458 


JOHN  M.  WHEELER 


which  is  made  up  of  epidermis  only,  free  from  layers  of  true  skin,  and 
large  enough  to  be  wrapped  around  the  form  of  impression  compound 
with  generous  overlapping.  This  means  a  graft  3}/£  to  4  inches  long 
and  about  3  inches  wide. 


Fig.  11. — Restoration  of  obliterated  socket.  Eyelids  retracted  to  show  dis- 
sected cavity  for  socket.  Orbital  margins  indicated  by  curved  dotted  line  above. 
Anterior  view  and  cross-section  of  form  of  dental  impression  compound  covered 
with  a  single  epidermic  graft  for  lining  of  new  socket. 


The  graft  of  epidermis  is  immediately  wrapped  about  the  form  of 
impression  compound,  raw  surface  outward,  and  overlapped  on  the 
surface  which  is  to  be  anterior.  The  form,  completely  covered  with 
epidermis,  is  forced  into  the  socket  cavity  (Fig.  11).  It  is  not  nec- 
essary to  remove  small  blood-clots  before  placing  it  as  they  will  not 


Plastic  Operations  About  the  Eye  459 

prevent  a  take.  The  overlapping  portion  of  the  graft  is  placed  for- 
ward so  that  if  the  edges  are  disturbed  by  manipulation  they  can  be 
carefully  replaced  through  the  palpebral  fissure  so  that  every  part  of 
the  form  will  be  covered. 

No  sutures  are  used.  A  pressure  bandage  is  applied,  and  over  this 
adhesive  strips.  Very  firm  pressure  is  of  importance  to  secure  accu- 
rate contact  at  all  points  and  to  keep  the  cavity  absolutely  obliterated. 
This  first  dressing  is  left  in  place  for  a  week.  The  form  is  left  in  place 
and  is  not  touched  for  about  three  weeks.  It  is  then  removed  and  left 
out  permanently.  The  artificial  eye  may  be  introduced  at  any  time. 

If  the  surgeon  has  been  successful  in  carrying  out  the  technic, 
the  result  will  be  a  permanent  socket,  extending  well  beyond  the  canthi 
and  of  sufficient  dimensions  all  around.  The  lids  will  be  normally  thin 
and  pliable,  and  the  thin-walled  socket  will  not  prohibit  motility  of 
the  stump  and  artificial  eye  although  the  movements  of  the  eye  will 
be  somewhat  less  than  those  following  ordinary  enucleation. 

An  interesting  development  is  that  usually  lacrimal  secretion  will 
find  its  way  into  the  new  socket  and  maintain  a  comfortable  moisture. 
As  far  as  I  know,  trouble  never  results  from  activity  of  the  lacrimal 
gland. 

DISCUSSION 

DR.  W.  E.  LAMBERT  (New  York  City) :  It  has  been  my  privilege  to  witness 
many  of  the  operations  which  Dr.  Wheeler  has  performed,  and  to  follow  up 
the  end  results,  and  I  simply  wish  to  express  my  admiration  for  the  skill 
which  he  has  displayed.  He  is  rather  modest  in  saying  that  the  restoration 
of  the  lid  margin  adheres  not  particularly  well.  I  recall  one  case  which 
showed  me  that  it  was  wonderful.  Not  only  does  it  require  a  great  deal  of 
skill  and  painstaking,  but  I  think  one  who  does  this  kind  of  surgery  must 
have  a  certain  temperament. 

DR.  JOHN  E.  WEEKS  (New  York  City) :  In  former  years,  before  asepsis  was 
thoroughly  understood,  the  great  question  involved  in  all  of  these  plastic 
operations  was  how  best  to  get  the  flap  to  take — what  sort  of  a  flap  would  be 
most  liable  to  give  the  results  desired.  Reverdin,  as  we  know,  first  taught  the 
use  of  flaps  without  a  pedicle  by  using  minute  particles  of  skin.  Then  Wolf 
followed  with  large  skin  flaps,  and  when  these  flaps  were  put  in  position  with- 
out infection  they  usually  took  well,  flaps  with  pedicles  being  safer  than  those 
without  pedicles.  The  recent  opportunity  for  great  experience  in  plastic 
operations  about  the  face,  with  our  knowledge  of  asepsis,  has  served  to 
revolutionize  our  ideas  regarding  plastic  surgery  about  the  eye  and  face,  and 
our  idea  that  flaps  with  pedicles  must  be  used  has  changed  entirely;  our  idea 
that  no  skin  must  be  used  has  changed.  With  a  knowledge  of  what  has 
preceded  the  modern  ophthalmologist  bases  his  operation  on  the  evidence 
that  has  been  accumulated.  Dr.  Wheeler  has  not  been  hampered  by  previous 


460  J.  N.  ROY 

knowledge.  He  has  overstepped  the  boundaries  laid  by  men  who  have 
preceded  him,  and  has  produced  results  far  superior  to  those  previously 
obtained. 

The  principle  of  operating  soon  after  the  injury  has  occurred  is  one  that  he 
has  changed  entirely.  Previously  we  had  the  impression  that  it  was  better 
to  wait  until  the  cicatrix  was  fully  formed  before  we  attempted  to  do  plastic 
surgery.  Dr.  Wheeler  has  demonstrated  that  we  may  operate  early  and  get 
most  excellent  results. 

DR.  J.  M.  WHEELER  (closing) :  I  have  been  asked  many  times  how  a  large 
epidermic  graft  such  as  I  have  described  can  be  taken.  It  requires  some 
training  and  some  patience  to  get  the  sort  of  graft  that  is  necessary  to  cover  a 
large  area.  I  have  found  that  the  instrument  makers  will  not  give  a  keen 
enough  edge  to  a  razor  or  knife  to  take  the  proper  kind  of  graft.  The  edge 
must  be  extremely  keen  and  evenly  keen.  If  there  is  any  place  that  is  not 
sharp,  you  are  sure  to  have  trouble.  An  interested  barber  can  get  a  keen 
edge  on  a  grafting  knife  if  you  explain  to  him  what  you  want,  and  he  will 
take  special  care  because  he  will  feel  that  it  is  the  most  important  work  he 
has  ever  done. 


LAGOPHTALMIE  BILATfiRALE  CONSECUTIVE  A  LA 

PERTE  ACCIDENTELLE  DE  LA  PEAU  DU  FRONT, 

ET  DU  CUIR  CHEVELU.    BLfiPHAROPLASTIE 

DOCTEUR  J.  N.  ROY 

Professeur  agrege  a  1'Universite  de  Montreal,  Medecin  de  l'H6tel-Dieu 
Montreal,  Canada 

OBSERVATION 

Le  28  octobre  1920,  la  soeur  M.  J.  agee  de  37  ans,  vient  nous  con- 
suiter  pour  une  lagophtalmie  double,  remontant  a  pres  d'un  quart  de 
siecle.  Elle  raconte  qu'a  12  ans,  un  jour  qu'elle  travaillait  dans  une 
buanderie  me*canique,  sa  chevelure  fut  prise  dans  une  courroie  qui  la 
souleva  jusqu'au  plafond.  Sa  tete  etant  venue  en  contact  avec  un 
soliveau,  elle  fut  instantane'ment  scalpe"e,  et  retomba  sur  le  plancher, 
sans  avoir  perdu  connaissance,  et  sans  avoir  a  de"plorer  de  fractures. 
La  plaie  frontale  se  limitait  aux  sourcils  qui  etaient  arrach^s,  celle  de 
la  region  temporale  faisait  une  encoche  a  la  partie  superieure  du 
pavilion  des  oreilles,  surtout  a  droite,  et  a  part  un  peu  de  cheveux  qui 
restaient  a  la  nuque,  toute  la  peau  du  crane  e"tait  disparue.  Les 
paupi£res  supe*rieures,  n'e"tant  plus  attire*es  en  haut,  se  retourn£rent 
et  recouvrirent  les  fentes  palp6brales.  La  douleur  fut  naturellement 
tr&s  vive,  et  Phe'morragie  considerable.  Des  linges  humides  froids 


Lagophtalmie  Bilaterale — Blepharoplastie  461 

furent  immediatement  appliques  en  attendant  le  medecin.  A  son 
arrivee,  celui-ci  fit  un  pansement  antiseptique  a  1'acide  phenique. 
Durant  les  quatre  semaines  qui  suivirent  1'accident,  des  hemorragies 
assez  frequentes  se  produisirent.  Le  perioste  etait  partout  intact, 
et  les  pansements  humides  a  1'acide  phenique  furent  continues  pen- 
dant trois  mois.  Apres  cette  periode,  ils  ne  furent  faits  que  la  nuit, 
et  le  jour  on  appliquait  de  1'acide  borique  en  poudre,  tout  en  laissant 
le  crane  a  decouvert.  Peu  de  temps  apres  ce  nouveau  genre  de  panse- 
ment alternatif,  un  eresipele  se  declara,  et  faillit  emporter  la  malade. 
Environ  six  mois  apr£s  le  traumatisme,  la  plaie  commenga  a  s'ame- 
liorer  et  les  paupieres,  grace  aux  pansements  compressifs  appropries, 
se  replacement  petit  a  petit;  toutefois  les  cantus  externes  eurent  des 
le  debut  une  tendance  a  etre  attires  en  haut.  Cette  traction  s'aug- 
mentant  toujours  par  1'epidermisation  de  la  peau  du  front  et  de  la 
tempe,  fit  qu'a  la  fin  de  la  premiere  annee,  la  malade  ne  pouvait  plus 
fermer  les  yeux.  Huit  ans  apres  1'accident,  une  keratite  double  par 
lagophtalmie  se  declara,  surtout  localisee  a  1'oeil  gauche.  L'oculiste 
consulte  prescrivit  le  traitement  ordinaire,  sans  oublier  naturellement 
le  bandeau  que  la  malade  ne  cessa  jamais  de  porter  la  nuit  depuis 
cette  epoque,  et  la  guerison  fut  complete  au  bout  de  deux  mois.  La 
region  fronto-temporale  fut  tres  lente  a  guerir,  puisqu'elle  prit  cinq 
ans  a  se  cicatriser.  Pendant  cette  periode,  la  lagophtalmie  augmenta 
toujours,  et  les  paupieres  superieures  devinrent  presque  immobiles. 
Les  oreilles  furent  attirees  en  haut.  La  region  occipitale  s'epidermisa 
assez  rapidement.  Quant  au  vertex,  il  fut  particulierement  rebel 
a  la  guerison,  bien  que  les  pansements  humides  a  1'acide  phenique 
fussent  repris  et  toujours  continues  depuis  son  infection  eresipelateuse. 
Dix-huit  ans  apres  1'accident,  un  eczema  envahit  la  region  fronto- 
temporale,  et  prit  une  anne"e  avant  de  disparaitre.  Comme  a  ce 
moment  la  plaie  du  crane  semblait  vouloir  s'eterniser,  un  chirurgien 
pratiqua  la  greffe  de  Thiersch.  II  fit  aussi  une  incision  dans  la  region 
du  cantus  externe  de  1'oeil  gauche,  des  tractions  et  des  pansements 
appropries,  dans  le  but  d'abaisser  la  paupiere  superieure  correspon- 
dante.  Malheureusement  ces  deux  interventions  ne  donnerent 
aucun  resultat,  car  une  seconde  infection  se  declara,  et  les  greffes 
furent  elimine'es.  Un  mois  apres  cette  premiere  tentative,  le  chirur- 
gien essaya  sur  le  vertex  la  greffe  dermo-epidermique  en  flots,  qui 
cette  fois  fut  tole're'e.  Pendant  les  six  annees  qui  suivirent,  1'ame'liora- 
tion  progressa  tres  lentement,  sans  toutefois  donner  un  resultat 
complet.  A  plusieurs  endroits,  la  cicatrisation  ne  voulait  pas  se  faire, 


462 


J.  N.  ROY 


des  croutes  se  formaient  pour  tomber  ensuite,  et  malgre  les  panse- 
ments  humides,  il  y  avait  toujours  de  la  suppuration. 

A  1'examen  des  yeux,  nous  constatons  deux  petites  taies  des  cornees. 
La  vision  est  cependant  excellente  apres  correction  d'un  l^ger  astig- 
matisme  hyperm£tropique. 

Quant  aux  paupieres,  il  existe  une  lagophtalmie  mecanique  des 
plus  considerables.  Les  cantus  externes,  d£colles  de  la  conjonctive 
oculaire,  sont  tres  fortement  attires  en  haut,  et  la  traction  est  encore 


Fig.  1 


plus  prononcee  a  droite  qu'a  gauche.  L'aspect  de  la  malade  rappelle, 
d'une  maniere  exageree,  le  type  caracteristique  de  la  race  mongolique. 
Lorsqu'elle  fait  un  effort  pour  fermer  les  yeux,  les  paupieres  bougent 
a  peine.  II  n'y  a  pas  d'ectropion. 

Les  sourcils  sont  entierement  disparus. 

La  peau  du  front  et  des  tempes  est  tres  mince,  sans  tissu  adipeux 
sous-jacent,  et  parcourue  par  un  grand  nombre  de  petits  vaisseaux 
sanguins  superficiels. 


Lagophtalmie  Bilaterale — Blepharoplastie  463 

L'oreille  gauche  est  remontee  de  quinze  millimetres  environ,  et  la 
droite  de  deux  centimetres. 

II  y  a  sur  le  vertex,  encore  incompletement  cicatrise,  une  dizaine  de 
petits  endroits  remplis  de  bourgeons,  ou  recouverts  de  croutes. 

La  region  occipitale  est  parfaitement  guerie,  et  il  existe  huit  centi- 
metres de  cuir  chevelu  a  la  partie  infer ieure  de  la  nuque. 

Apres  nous  avoir  fait  part  des  ennuis  resultant  de  la  lagophtalmie, 
la  malade  nous  explique  jusqu'a  quel  point  est  desagreable  la  sensa- 
tion de  traction  continuelle  de  ses  cantus  extern'es.  Aussi  est-ce 
avec  une  certaine  anxie"te  qu'elle  nous  demande  si  nous  pouvons  la 
guerir.  Sur  notre  reponse  affirmative,  et  apres  1' avoir  mise  au 
courant  de  ce  qui  devait  etre  fait  dans  son  cas,  elle  accepte  immediate- 
ment  Foperation  qui,  pour  des  raisons  personnelles,  est  fixe"e  au  4 
decembre.  A  cette  epoque,  1'apparence  de  la  patiente  est  celle  indi- 
quee  par  la  photographic  No.  1. 

OPERATION 

Apres  avoir  decide  de  commencer  par  le  cote  gauche,  toute  la  partie 
sur  laquelle  nous  devions  intervenir  etant  parfaitement  sterilisee, 
nous  faisons  a  la  region  fronto-temporale  et  sur  la  joue,  une  serie 
d'injections  de  novocaine-adrenaline.  Une  incision  de  cinq  centi- 
metres environ  est  ensuite  pratiquee,  se  terminant  un  peu  en  bas  et 
a  onze  millimetres  du  cantus  externe.  Cette  incision  est  tres  legere- 
ment  concavo-convexe,  a  direction  inferieure,  et  se  trouve  a  traverser 
1'emplacement  du  tiers  externe  du  sourcil  arrache.  Apres  avoir 
largement  disseque  toute  la  region  environnant  le  cantus,  nous  reus- 
sissons  a  abaisser  sumsamment  les  paupieres  pour  leur  donner  une  posi- 
tion tout  a  fait  horizontale.  Ann  de  combler  cette  plaie  entr'ouverte, 
nous  prelevons  sur  la  joue  un  lam  beau  de  sept  centimetres  environ 
de  longueur  sur  quinze  millimetres  de  largeur  dans  son  plus  grand 
diametre  qui,  une  fois  detache,  est  mis  en  place.  Dans  le  but  d'im- 
mobiliser  le  cantus,  et  d'empecher  qu'il  remonte  de  nouveau  pendant 
la  cicatrisation  post-operatoire,  nous  Fattirons  en  bas  au  moyen  d'un 
catgut  passe  dans  le  perioste  de  la  region  malaire.  Le  lambeau 
fronto-temporal  est  soigneusement  sutture  a  la  soie,  et  apres  avoir 
decolle  la  peau  adjacente  a  1'incision  jugale,  les  levres  de  la  plaie  sont 
facilement  coaptees  et  maintenues  en  place  au  moyen  de  crins  de 
florence.  Finalement  nous  appliquons  un  pansement  legerement 
serre,  et  le  plagons  de  telle  sorte  que  la  compression  se  fasse  de  haut 
en  bas.  Les  suites  operatoires  sont  des  plus  simples,  et  la  plaie  guerit 
par  premiere  intention. 


464 


J.  N.  ROY 


Comme  la  malade  est  tres  de"sireuse  d'etre  retablie  le  plus  tot  pos- 
sible, nous  intervenons  a  droite  dix  jours  apres  la  premiere  operation. 
La  technique  suivie  e"tant  tout  a  fait  semblable  pour  les  deux  cotes, 
nous  ne  croyons  pas  devoir  la  de"crire  de  nouveau.  Cependant  comme 
le  cantus  externe  e"tait  un  peu  plus  releve  a  droite  qu'a  gauche,  sa 
dissection  fut  plus  laborieuse  pour  parvenir  a  un  abaissement  com- 
plet.  Encore  cette  fois,  les  suites  ope"ratoires  eVoluent  sans  incident 
et  nous  obtenons  une  reunion  par  premiere  intention.  Un  soin  par- 


Fig.  2 


ticulier  est  apporte"  aux  pansements,  et  grace  a  la  plus  ou  moins  forte 
compression  pratique"e  de  haut  en  bas,  nous  augmentons  1'effet  de 
notre  operation,  et  re*ussissons  a  avoir  deux  fentes  palpebrales  par- 
faitement  symetriques  et  horizontales.  La  malade  pent  maintenant 
fermer  les  yeux  sans  effort,  et  comme  le  releveur  des  paupi^res  su- 
pe"rieures  n'avait  pas  e"te  l^se  lors  de  1'accident,  elle  peut  aussi  les 
ouvrir  normalement.  La  conjonctive  palp6brale  des  cantus  externes 
est  en  contact  avec  la  conjonctive  oculaire,  et  il  n'existe  aucune  trac- 


Lagophtalmie  Bilaterale — Blepharoplastie 


465 


tion  disgracieuse  de  cette  partie.     A  la  fin  de  decembre  la  patiente 
est  assez  bien  pour  retourner  dans  sa  communaute. 

Naturellement  nous  avions  profile  de  son  sejour  a  1'hopital  pour 
trailer  ses  petites  plaies  craniennes  au  moyen  de  pansements  humides, 
de  curettages  des  bourgeons  et  d 'applications  de  teinture  d'iode. 
Ce  traitement,  continue  dans  la  suite,  amena  une  forte  amelioration 


Fig.  3 


sans  toutefois  donner  une  guerison  complete.  Pour  atteindre  ce 
but,  il  faudrait,  croyons-nous,  pratiquer  encore  quelquesgreffes  dermo- 
epidermiques,  vu  la  tres  mauvaise  nutrition  de  tout  le  tissu  cicatriciel 
cranien. 

Le  26  fevrier  et  le  8  mars  1921,  nous  faisons  sous  anesthetic  locale, 
une  petite  autoplastie  des  pedicules  de  nos  lambeaux  indiens.  Comme 
ceux-ci  avaient  ete  tailles  avec  assez  de  precision,  et  qu'il  n'existait 
pas  de  bourrelets  cutanes  a  la  region  sourciliere,  nous  ne  sommes  pas 
obliges  d'y  faire  de  retouches. 
30 


466  J.  N.  ROY 

Apres  gue"rison  complete  de  ces  deux  plaies,  nous  proposons  a  la 
malade  de  tenter  la  greffe  des  sourcils  que  nous  aurions  prelevee  sur 
ce  qui  restait  de  cuir  chevelu  a  la  partie  inferieure  de  la  nuque.  Etant 
donne"  que  son  lambeau  frontal,  porte  dans  sa  communaute",  en  mas- 
que 1'absence,  et  qu'elle  est  enchante*e  du  resultat  operatoire  obtenu, 
elle  refuse  cette  derniere  intervention.  Les  paupieres,  sur  un  plan 
bien  horizontal,  se  ferment  avec  la  plus  grande  facilite,  et  les  yeux 
s'ouvrent  sans  effort — ,d'ailleurs  comme  il  peut  6tre  constate  sur  les 
photographies  2  et  3,  prises  le  7  avril. 

L'operee,  revue  en  de"cembre  1921,  est  toujours  dans  le  meme  etat, 
et  a  peine  existe-t-il  quelques  traces  de  ses  incisions  cutanees. 

En  publiant  cette  observation,  nous  n'avons  pas  la  prevention  de 
preconiser  une  me*thode  nouvelle  de  blepharoplastie.  Nous  nous 
sommes  simplement  inspire  de  1'experience  personnellement  acquise 
pendant  la  re*cente  guerre,  en  fait  de  chirurgie  de  la  face  et  des  pau- 
pieres, en  choisissant  1'unique  precede  rationnel  dans  le  cas  present. 
En  effet,  avec  la  greffe  dermo-e'pidermique,  nous  aurions  probable- 
ment  couru  vers  un  echec,  car,  meme  si  elle  avait  ete  pratiquee 
d'une  maniere  impeccable  au  point  de  vue  de  Pasepsie  et  de  la  taille 
d'un  lambeau  suffisamment  grand,  il  ne  faut  pas  oublier  que  notre 
intervention  portait  sur  un  tissu  tres  mince  et  mal  nourri. 

Ann  de  sauvegarder  Pesthetique  de  la  face,  nous  aurions  pu  nous 
servir  du  precede  de  Snydacker  de  Chicago,  en  prenant  un  lambeau 
pedicule  sur  le  cou.  Toutefois  ce  precede  aurait  produit  un  trau- 
matisme  operatoire  beaucoup  plus  considerable  que  celui  employe 
chez  notre  patiente,  et  n'aurait  pas  eu  sa  raison  d'etre  dans  le  seul 
but  d'eviter  une  cicatrice  jugale  maintenant  a  peine  perceptible. 

Comme  il  etait  nullement  question  dans  notre  cas  de  recourir  a 
la  methode  italienne,  il  nous  restait  done,  pour  combler  1'espace  pro- 
duit par  1'incision  et  1'abaissement  du  cantus  externe,  qu'a  prendre 
sur  la  joue,  au  voisinage  immediat  de  la  plaie,  un  lambeau  approprie, 
ce  qui  revenait  a  choisir  la  me'thode  indienne.  D'ailleurs  les  differents 
precedes  de  blepharoplastie  sont  maintenant  bien  connus,  surtout 
depuis  les  remarquables  travaux  de  Morax  de  Paris,  qui  est  certaine- 
ment  Poculiste  possedant  la  plus  grande  experience  en  chirurgie  pal- 
pebrale.  Nous-memes  avons  eu  Poccasion  de  publier  un  certain 
nombre  de  memoires  sur  les  greffes  osseuses  et  cartilagineuses, — que 
dans  la  pre*sente  communication,  nous  passerons  sous  silence — et 
sur  les  autoplasties  de  la  face  en  general,  dans  lesquels  nous  avons 
expose"  les  meilleures  me'thodes  &  pre'fe'rer  dans  chaque  cas  particulier. 


Lagophtalmie  Bilaterale — Blepharoplastie  467 

Pour  celui-ci,  nous  attirons  1'attention  sur  le  fait  de  nous  etre  servi 
de  deux  catguts  passes  dans  les  cantus  et  attaches  au  perioste  malaire, 
ce  qui  a  grandement  contribue  a  les  stabiliser.  Le  pansement,  corn- 
prime  de  haut  en  bas,  a  egalement  augmente  1'effet  de  notre  interven- 
tion. 

Si  la  malade  en  avait  manifesto  le  desir,  nous  aurions  volontiers 
essaye  de  lui  greffer  des  sourcils,  sans  toutefois  etre  certain  du  succes, 
etant  donne  la  mauvaise  qualite  de  la  peau  et  des  tissus  sous-jacents, 
qui  auraient  eu  le  role  de  nourrir  ces  greffes.  Aussi,  en  presence  du 
resultat  obtenu,  nous  avons  lieu  d'etre  satisfait  du  precede  chojsi. 


BIBLIOGRAPHIE 

J.  P.  de  Carvalho:  Autoplastie  palpebro-faciale  a  lambeau  p&iicule"  cervical  (pro- 
cede  de  Snydacker)  avec  ou  sans  utilisation  du  pedicule  (technique  modifie 
par  Morax),  These  de  Paris,  1918. 

-  Traitement  de  certaines  mutilations  palpebrales  de  guerre  par  le  precede 
autoplastique  de  Snydacker-Morax,  Annales  d'Oculistique,  octobre,  1919. 

M.  Kalt:  Restauration  d'une  paupiere  totalement  detruite  par  le  moyen  d'un 
lambeau  a  double  face,  Annales  d'Oculistique,  septembre,  1919. 

V.  Morax:  L' Autoplastie  palpebrale  ou  faciale  a  1'aide  de  lambeaux  pedicules 
empruntes  a  la  region  cervicale  (precede  de  Snydacker)  et  1'autoplastie 
en  deux  temps  avec  utilisation  du  pedicule,  Annales  d'Oculistique,  Janvier, 
1908. 

Plastic  operations  on  the  orbital  region  including  restoration  of  the  eye- 
brows, eyelids  and  orbital  cavity.     The  Bowman  lecture,  Transactions  of 
the  Ophthalmological  Society,  xxxix,  1919. 

V.  Morax  et  R.  Beal:  Nsevus  pigmentaire  du  front  et  du  sourcil  avec  dermoi'de 
conjonctival.  Autoplastie  fronto-sourciliere  en  deux  temps  a  lambeau 
pedicule  emprunte  a  la  region  cervicale,  Annales  d'Oculistique,  Janvier, 
1908. 

G.  DuPont  et  J.  N.  Roy:  Cancer  des  paupieres  et  de  1'orbite.  Autoplastie,  Le 
Journal  de  Medecine  et  de  Chirurgie,  Mars,  1910. 

J.  N.  Roy:  Autoplastie  de  la  face  pour  un  epithelioma  des  paupieres,  Le  Journal 
de  M6decine  et  de  Chirurgie,  Mars,  1908. 

Quelques  cas  de  labioplastie  (chirurgie  de  guerre),  L'Union  Medicale  du 

Canada,  avril,  1919. 

Perforating  Gunshot  Wound  of  the  Face  with  Extensive  Destruction  of 

the  Superior  Maxillae  (War  Surgery),  The  Laryngoscope,  February,  1920. 

La  autoplastia  adiposa  facial  (cirurgia  de  la  guerra),  Cr6nica  medico- 

quinirgica  de  la  Habana,  Julio,  1921. 

Plaie  penetrante  du  nez.     Autoplastie  avec  lambeau  indien   (chirurgie 

de  guerre),  L'Uni6n  medicale  du  Canada,  aout,  1921. 
E.  F.  Snydacker:    A  Plastic  Operation  of  the  Eyelids  by  Means  of  Skin  Flaps 

Taken  From  the  Neck,  Archives  of  Ophthalmology,  January,  1906. 

Lidplastik  mit  gestieltem  Lappen  vom  Halse,  Monatsblatter  fur  Augen- 

heilkunde,  Januar,  1907. 


LIGHT-SENSE:  THE  PRACTICAL  SIGNIFICANCE  OF 

ITS  VARIATIONS:  SIMPLE  TESTS  FOR 

DETERMINING  THEM 

ARCHIBALD  STANLEY  PERCIVAL,  M.A.,  M.B.,  B.C.  Camb. 

Senior  Surgeon  to  the  Newcastle-on-Tyne  Eye  Infirmary 

Newcastle-on-Tyne,  England 

I  deeply  regret  that  I  have  been  unable  to  attend  this  International 
Congress  and  that  I  have  missed  this  opportunity  of  learning  so  much 
from  ophthalmologists  of  world-wide  reputation.  I  would  now  express 
my  thanks  to  the  Committee  for  allowing  me  to  present  this  paper  for 
your  criticism  in  my  absence. 

Light-sense  is  the  faculty  of  recognizing  different  luminous  intensi- 
ties. Too  little  attention  has  been  paid  to  the  sensibility  of  the  eye  to 
variations  in  the  light  stimulus,  although  this  may  be  of  extreme  im- 
portance in  certain  services.  We  are  asked  for  a  report  on  a  candi- 
date's sight,  and  we  send  a  report  of  his  visual  acuity;  i.  e.,  of  his 
macular  form-sense  (without  and  with  correcting  glasses,  should  he 
require  any) .  A  man  may  have  a  visual  acuity  of  6/6  and  yet  unless 
we  examine  his  light-sense  we  may  miss  the  fact  that  he  is  night- 
blind.  Of  what  use  is  such  a  man,  when  on  watch  at  sea,  in  detecting 
an  object,  whether  a  derelict  or  an  iceberg,  in  the  ship's  course  at 
night? 

You  will  all  have  noticed  at  nightfall,  when  there  is  no  moon,  that 
as  the  light  begins  to  fail  that  red  colors  become  much  darker,  and 
presently  a  red  geranium  will  appear  quite  black  and  the  grass  grayish, 
although  yellow  and  blue  flowers  can  still  be  seen ;  for  a  time  the  blue 
flowers  appear  extraordinarily  brilliant,  as  all  other  colors  are  unrec- 
ognizable, and  then  finally,  as  the  darkness  deepens,  blue  disappears, 
and  one  becomes  totally  color  blind.  This  successive  disappearance  of 
colors  is  called  Purkinje's  phenomenon. 

When  this  stage  of  dark-adaptation,  or  scotopia  as  it  is  called,  is 
reached,  one  can  still  dimly  see  objects  by  their  differing  depths  of 
grayness,  but  it  will  be  found  that  one  sees  best  by  looking  a  little  to 
one  side  of  them.  Arago  first  called  the  attention  of  astronomers  to 

468 


Light-sense:  Simple  Tests  for  Determining 


469 


this  point,  telling  them  that  they  could  best  get  a  glimpse  of  a  very 
faint  star  by  looking  a  few  degrees  away  from  it.  It  will  be  found  that 
in  complete  scotopia  the  fovea  is  a  blind  spot;  i.  e.,  there  is  a  central 
scotoma  in  the  rod-free  area  of  the  retina. 

Normally  with  full  illumination  the  visual  acuity  or  form-sense 
diminishes  very  rapidly  from  the  fovea  toward  the  periphery.  With  a 
foveal  acuity  of  6/6,  at  5°  distance  the  acuity  is  6/24,  at  10°  4/60  and 
so  on.  In  a  very  dim  illumination  light  sense  is  absent  at  the  fovea, 
and  is  at  a  maximum  about  10°  from  the  fovea. 


Fovea 

5° 

10° 

15° 

Form-sense    

6/6 

6/24 

4/60 

2/60 

Full  illumination 

Light-sense  

0 

Good 

Max. 

Good 

Dim  illumination 

Now  the  fovea  subtends  an  angle  of  about  1°  and  the  rod-free  area 
an  angle  of  about  3°  at  the  second  nodal  point  of  the  eye;  beyond 
this  area  rods  appear  in  increasing  numbers  and  cones  become  less  and 
less  as  one  proceeds  towards  the  periphery.  One  is,  therefore,  led 
to  think  that  rods,  or  something  associated  with  rods,  must  be  the 
percipient  elements  for  light-sense. 

Comparative  anatomy  supports  this  view.  With  one  exception  all 
nocturnal  animals  possess  an  excessive  number  of  rods  which  are  espe- 
cially long,  and  a  very  ill-developed  fovea,  whereas  all  diurnal  animals 
have  a  well-developed  fovea  and  a  far  greater  number  of  cones.  A  very 
striking  example  of  this  peculiarity  is  found  in  the  family  of  Saurians. 
All  the  diurnal  lizards  (e.  g.,  the  chameleon)  possess  only  cones,  while 
the  nocturnal  lizards  or  geckos  have  only  rods. 

The  exception  mentioned  above  is  the  nocturnal  tortoise  which  has 
only  cones;  but  the  tortoise  is  peculiar,  it  moves  so  slowly  that  it 
can  neither  escape  from  its  enemy  nor  pursue  its  prey,  and  it  is  quite 
possible  that  it  may  be  guided  to  the  insects  and  plants  it  eats  by  scent 
alone. 

When  we  pass  from  bright  sunlight  to  a  very  dimly  lighted  room  we 
can  see  nothing  until  our  eyes  have  become  scotopic  or  adapted  to  the 
dark.  In  order  to  obtain  full  dark -adaptation  it  is  necessary  to  remain 
in  an  absolutely  dark  room  for  three-quarters  of  an  hour  or  so,  and 
then  some  very  curious  phenomena  are  found.  In  scotopia  the  light- 
sense  is  about  twice  as  great  with  both  eyes  as  with  only  one,  again  if 


470  ARCHIBALD  STANLEY  PERCIVAL 

an  object  be  illuminated  by  a  dim  composite  white  light  the  retinal 
sensibility  is  proportional  to  the  square  root  of  the  area  stimulated.  In 
light-adapted  eyes  there  is  no  such  binocular  summation  of  stimuli, 
nor,  if  the  retinal  area  stimulated  exceeds  I',  is  there  any  increase  of 
brightness  from  stimulating  a  larger  area. 

Prof.  E.  M.  Barnard  some  years  ago  caused  great  consternation 
among  the  pundits  of  ophthalmology  owing  to  their  ignorance  of  this 
fact.  He  found  that  he  could  detect  a  wire  at  such  a  distance  that  its 
diameter  only  subtended  an  angle  of  0'.44".  Most  people  jumped  to 
the  conclusion  that  his  minimum  visual  angle  was  less  than  half  a 
second  and  that  it  was  his  form-sense  that  was  being  tested.  The 
minimum  visual  angle  for  form-sense  is  53",  and  for  convenience  is 
usually  assumed  to  be  1',  so  many  discredited  his  observation.  This 
was  absurd  for  Prof.  Barnard  is  known  throughout  the  world  for  his 
reliable  and  accurate  observations  at  the  Yerkes  Observatory.  We 
can  see  that  it  has  nothing  to  do  with  his  form-sense,  it  was  only  a 
proof  of  his  great  sensibility  to  light  difference.  If  you  try,  as  I  have 
done,  putting  up  a  fine  wire  16  feet  long  horizontally  against  the  sky, 
you  will  see  it  quite  easily  at  a  considerable  distance,  but  if  you  block 
out  from  your  view  all  but  a  foot  of  it,  you  will  not  see  it  at  all,  as  its 
effect  on  your  retinal  sensibility  is  only  one-fourth  of  what  it  was,  thus 
showing  that  as  it  obeys  the  square  root  area  law  it  must  be  a  light- 
sense,  not  a  form-sense,  test. 

The  subject  is  a  very  difficult  one,  as  most  of  our  so-called  form- 
sense  tests  are  really  composite  tests  of  our  light-sense  also;  as,  for 
instance,  especially  the  common  dot  tests  and  even  Landolt's  excellent 
broken  ring  tests. 

Now  visual  purple  or  rhodopsin  occurs  according  to  Kiihne  in  the 
rods  only,  and  there  is  good  evidence  to  show  that  rhodopsin  plays  a 
very  important  part  in  the  physiology  of  light-sense.  When  a  spec- 
trum of  very  low  intensity  is  viewed  in  the  dark  by  a  scotopic  eye,  it 
appears  as  a  colorless  gray  streak,  the  brightest  part  of  which  is  in  the 
green  ( X  =  5300  A.  U.)  and  not  about  X  =  5800  A.  U.  in  the  neighbor- 
hood of  the  D  line,  as  is  the  case  in  the  normal  photopic  eye.  The 
luminosity  curve  seems  to  be  bodily  shifted  toward  the  violet  end  of 
the  spectrum  as  the  red  end  is  shortened,  it  is  in  fact  exactly  similar 
to  the  luminosity  curves  of  the  totally  color  blind.  Then  again  the 
bleaching  effect  of  light  on  a  frog's  rhodopsin  is  greatest  when  it  is  of 
wave  length  5300  A.  U.  (in  the  green).  For  these  and  further  details 
I  would  refer  every  earnest  inquirer  to  Parsons'  excellent  "Color 


Light-sense:  Simple  Tests  for  Determining  471 

Vision"  (published  at  the  University  Press,  Cambridge),  to  which 
much  of  this  paper  is  due. 

You  will,  however,  be  wearied  with  all  this  academic  stuff,  and  be 
anxious  to  know  what  practical  bearing  it  has  on  diagnosis,  so  I  turn 
now  to  this  aspect  of  the  subject. 

Light-sense  is  tested  in  two  different  ways :  (1)  The  discovery  of  the 
smallest  quantity  of  light  that  can  be  recognized  on  a  black  back- 
ground; this  is  called  the  light  minimum  test,  and  is  always  referred  to 
as  L.  M.;  and  (2)  the  smallest  difference  of  illumination  that  can  be 
appreciated  between  two  sources  of  nearly  equal  luminosity.  This  is 
called  the  light  difference  test  and  is  always  denoted  by  L.  D. 

Now  the  important  practical  point  is  that  the  sense  for  L.  M.  is 
always  most  affected  if  the  receptive  part  of  the  retina  is  most  impli- 
cated; i.  e.,  in  affections  of  the  bacillary  layer,  the  visual  purple,  and 
the  choroid  on  which  the  efficiency  of  the  visual  purple  depends; 
whereas  the  sense  for  L.  D.  fails  if  the  conductive  part  of  the  visual 
function  is  primarily  at  fault.  For  instance,  in  optic  neuritis  and  in 
retrobulbar  neuritis  L.  D.  is  at  fault.  An  easy  memoria  technica  is  to 
associate  L.  D.  with  o.  d.,  the  optic  disc,  but  I  wish  to  emphasize  the 
point  that  L.  D.  fails  also  when  the  nerve  fibrils  in  the  retina  are 
chiefly  affected.  This  I  have  only  recently  found  out.  In  all  previous 
publications  that  I  have  seen  on  the  subject  it  has  been  stated  that 
defective  light  difference  was  diagnostic  of  a  lesion  in  the  optic  nerve. 
This  hasty  assumption  was  no  doubt  due  to  the  very  troublesome 
apparatus  that  was  used  for  testing  light-sense.  With  my  simple  little 
rotating  disc  the  whole  examination  need  not  take  longer  than  three 
minutes,  and  so  more  experience  of  the  diagnostic  value  of  light-sense 
phenomena  can  be  gained  in  a  week's  hospital  practice  than  could  be 
formerly  attained  in  a  year,  unless  one's  whole  time  were  devoted  to 
the  subject. 

I  long  ago  found  that  toxic  amblyopia  was  always  associated  with  a 
L.  D.  defect,  and  yet  we  most  of  us  suspect  the  lesion  to  be  in  the 
ganglionic  layer  of  the  retina.  It  was  Dr.  Traquair,  to  whom  I  pointed 
out  my  difficulty,  who  suggested  the  association  of  L.  D.  defects  with 
lesions  of  the  conducting  apparatus  instead  of  simply  confining  them 
to  those  of  the  optic  nerve.  I  have  verified  this  suggestion  by  finding 
L.  D.  defects  in  several  cases  of  retinitis.  I  now  think  that  if  the  super- 
ficial layers  of  the  retina  are  affected  a  L.  D.  defect  will  be  found,  but 
if  the  deeper  layer  (of  the  rods  and  cones)  or  if  the  choroid  be  at  fault 
there  will  be  a  L.  M.  defect. 


472  ARCHIBALD  STANLEY  PERCIVAL 

In  all  the  cases  of  early  glaucoma  that  I  have  examined  in  this  way, 
I  have  always  found  a  L.  M.  defect  as  the  earliest  symptom,  and  that 
it  was  afterwards  followed  by  a  L.  D.  defect.  I  suggest  as  an  explana- 
tion of  this  that  the  bacillary  layer  is  more  sensitive  to  slight  pressure 
than  the*  nerve-fibers.  My  observations  need  most  careful  confirma- 
tion, and  I  would  be  exceedingly  grateful  to  any  of  you  if  you  can 
confirm  or  refute  them.  It  is  most  important  to  obtain  a  really  re- 
liable indication  of  the  first  onset  of  chronic  glaucoma,  and  I  believe 
that  the  light-sense  test  will  be  found  to  be  far  more  trustworthy  than 
any  single  tonometric  reading.  I  think  that  too  much  reliance  is  now 
placed  upon  the  tonometer;  we  all  know  that  there  are  fairly  wide 
physiologic  variations  from  what  is  regarded  as  the  standard  reading. 
On  physical  grounds  the  reading  must  depend  upon  the  stiffness  of  the 
cornea,  on  the  size  of  the  eyeball,  etc.,  as  well  as  upon  the  tension  of 
its  contents,  so  that  although  a  series  of  tonometric  readings  taken 
every  week  on  the  same  case  has  a  very  great  value,  undue  weight 
should  not  be  given  to  one  isolated  observation. 

In  cases  of  early  cataract  or  hazy  media  when  no  details  of  the  fun- 
dus  can  be  seen  with  the  ophthalmoscope,  it  is  often  of  extreme  im- 
portance to  obtain  some  indication  of  the  condition  of  the  structures 
at  the  back  of  the  eye.  An  examination  of  the  light-sense  of  the 
patient  helps  us  out  of  the  difficulty.  If  you  view  these  rotating  discs 
through  dark-tinted  glasses,  you  will  find  that  both  your  L.  M.  and 
your  L.  D.  perception  is  as  good  as  without  the  dark  glasses.  This  is 
no  doubt  due  to  the  partial  scotopia  induced  by  the  dark  glasses.  If 
the  obscuration  is  very  great,  the  L.  M.  and  the  L.  D.  perception  will 
fail  almost  equally. 

Two  months  ago  I  was  consulted  by  a  new  patient  for  cataract  who 
told  me  that  now  she  was  quite  sure  that  her  right  eye  was  ready  for 
operation.  With  the  ophthalmoscope  I  could  only  see  a  very  dim 
red  reflex,  but  on  testing  her  light-sense  I  found  that  both  L.  M.  and 
L.  D.  perceptions  were  very  defective  but  especially  her  L.  M.  sense 
(L.  M.  less  than  12.5,  L.  D.  =  50,  according  to  my  nomenclature 
where  the  standard  is  L.  M.  =  200,  L.  D.  =  100).  I  concluded  that 
there  was  probably  a  macular  hemorrhage  present,  as  projection  was 
good,  or  fairly  good.  Needless  to  say  I  did  not  recommend  an  opera- 
tion on  that  eye,  and  it  was  the  light-sense  test  that  saved  me  from  a 
disastrous  operation. 

We  know  that,  unlike  form-sense,  light-sense  is  fairly  good  even  to 


Light-sense:  Simple  Tests  for  Determining  473 

the  periphery  of  the  field,  and  this  peripheral  or  rod  vision  is  of  far 
more  importance  than  most  people  think.  All  must  have  noticed  how 
very  readily  one  notices  a  movement  of  any  object  in  the  peripheral 
field,  and  so  the  eyes  are  turned  in  that  direction  to  see  clearly  with 
the  maculae  what  it  is.  Indeed,  as  the  projection  from  the  periphery  is 
so  good  it  is  often  unnecessary  to  turn  one's  eyes  toward  the  object. 
In  a  town  one  avoids  bumping  up  against  passers-by  not  by  macular 
vision  but  by  peripheral  or  rod  vision,  i.  e.,  by  light-sense  not  by  form- 
sense.  Without  good  light-sense  one  will  not  see  what  to  look  at.  The 
British  Board  of  Trade  ordains  that  seamen  should  pass  a  very  high 
standard  of  tests  for  macular  visual  acuity,  but  pays  little  regard  to 
light-sense.  Quickness  of  sight — to  see  an  iceberg  in  twilight,  for  in- 
stance— is  what  is  wanted,  not  ability  to  determine  details  about  its 
shape  that  subtend  angles  of  one  minute. 

Light-sense  is  the  most  primitive  of  the  visual  functions  and  is, 
therefore,  the  last  to  be  lost  in  ordinary  cases  of  amblyopia.  At  any 
rate  in  children  with  an  amblyopic  squinting  eye  in  which  the  form- 
sense  may  be  diminished  to  6/36  or  even  less,  its  light-sense  will 
usually,  if  not  always,  be  found  very  good,  often  better  than  in  the 
normal  eye;  however,  in  later  life  this  extraordinary  light  perception 
seems  to  be  lost. 

There  are  some  curious  points  about  night-blindness  that  I  have  not 
the  time  here  to  discuss,  for  these  and  other  matters  I  would  refer  you 
to  a  paper  of  mine  on  Light-sense  published  in  the  Transactions  of  the 
Ophthalmological  Society  of  the  United  Kingdom,  vol.  xl,  1920. 

PERCIVAL'S  LIGHT-SENSE  TESTS 

The  test  can  be  made  in  ordinary  daylight  by  rotating  these  cellu- 
loid discs  on  any  convenient  rotor  or  by  spinning  them  on  an  ordi- 
nary dissecting  needle. 

L.  M.  Discs. — There  are  two  black  discs,  on  each  of  which  are  three 
white  sectors  of  different  sizes,  when  one  of  these  discs  is  rotated  three 
lighter  rings  are  seen  of  which  the  inner  is  the  lightest.  On  the  disc 
with  the  large  sectors,  the  inner  ring  denotes  a  L.  M.  of  1/12.5,  the 
intermediate  ring  1/25,  the  outer  1/50,  which  it  is  more  convenient  to 
denote  by  12.5,  25  and  50  as  ability  to  see  the  outer  ring  denotes  a 
better  light  minimum  sense  than  that  which  can  only  see  the  inner 
ring.  Similarly  the  disc  with  the  smaller  sectors  denotes  L.  M.  of 
values  50,  100  and  200. 


474  ARCHIBALD  STANLEY  PERCIVAL 

L.  D.  Discs. — These  are  white  discs  with  black  sectors  of  corre- 
spondingly different  sizes,  and  when  rotated  indicate  the  light  dif- 
ference sense  for  values  of  12.5,  25,  50  and  50,  100  and  200. 

It  will  be  noticed  that  a  light-sense  of  either  kind,  of  value  50,  is 
given  twice ;  this  is  often  useful  in  forming  an  opinion  of  the  reliability 
of  the  statements  of  the  patient. 

It  will  be  found  that  few  can  distinguish  the  faint  gray  ring  that 
corresponds  to  L.  D.  =  200,  and  so  I  assume  that  the  standard  for 
L.  D.  is  100,  while  that  for  L.  M.  is  200. 

It  might  be  hastily  assumed  that  the  size  of  the  black  sector  denot- 
ing L.  D.  =  100  should  be  of  angular  aperture  f f$°  or  3°  36",  but  as 
Abney  has  shown  us  that  5  per  cent,  of  the  incident  light  is  reflected 
from  lampblack,  we  must  add  1/19  to  the  angle,  so  that  this  sector 
must  be  of  3°  47'  22";  similar  additions  have  been  given  to  the 
other  sectors. 

DISCUSSION 

DR.  C.  E.  FERREE  (Bryn  Mawr,  Pa.) :  Mr.  Percival  expresses  the  hope  that 
his  conclusions  with  regard  to  the  light  difference  and  light  minimum  will 
receive  a  wider  confirmation  than  he  has  given  them.  It  may  be  of  interest 
in  this  connection  to  note  that  we  are  just  beginning  a  long  study  of  the  appli- 
cation of  functional  testing  to  the  diagnosis  of  eye  diseases  at  the  Polyclinic 
Hospital  of  the  Graduate  Medical  College  of  the  University  of  Pennsylvania. 
This  study  will  include,  among  others,  determinations  of  the  light  minimum 
and  light  difference,  also  the  color  minimum  and  color  difference,  with  appa- 
ratus which  permits  of  finely  graded  changes  of  intensity  and  the  exact  speci- 
fication of  the  amounts  of  light  used  in  every  case. 

In  Mr.  Percival's  test  for  the  light  minimum  the  task  set  for  the  patient  is 
the  discrimination  of  the  gray  just  noticeably  lighter  than  black  (coefficient 
of  reflection,  4-6  per  cent.)  with  the  eye  adapted  or  sensitized  to  high  or  day- 
light intensities  of  illumination.  The  light  difference  is  determined  under  the 
same  conditions  of  adaptation.  This  can  scarcely  be  said  to  test  the  eye  for 
scotopic  or  twilight  vision.  Of  course  these  two  determinations  can  be  made 
with  the  eye  in  any  state  of  adaptation  and  it  may  be  of  great  diagnostic 
value  to  make  them  with  the  eye  in  a  photopic  state  of  adaptation  as  is  done 
in  Mr.  Percival's  tests;  however,  since  a  disturbance  of  the  process  of  dark- 
adaptation  is  believed  by  many  to  be  characteristic  of  certain  types  of  disease, 
it  seems  to  me  to  be  important  to  make  the  test  also  with  the  eye  dark  adapted. 
This  does  not  seem  to  be  possible  with  the  discs  described  by  Mr.  Percival. 
Mr.  Percival's  tests  also  should  be  made  with  a  constant  intensity  of  light  on 
the  discs.  The  Fechner  fraction  or  the  ratio  expressing  the  value  of  the  light 
difference  is  independent  of  the  intensity  of  illumination  only  over  com- 
paratively small  ranges  of  change. 

The  type  of  disc  used  by  Mr.  Percival  was  first  described  by  Masson  in 
1845.  It  was  much  used  by  the  earlier  psychophysicists:  Fechner,  Aubert, 


Light-sense:  Simple  Tests  for  Determining  475 

Delboeuf,  Helmholtz,  Miiller,  Kraepelin,  Schirmer,  and  others,  for  the  de- 
termination of  the  light  difference.  Its  advantages  for  this  purpose  in  clinic 
work  are  its  very  great  simplicity  and  the  speed  with  which  it  can  be  used. 
Some  of  its  disadvantages  are  its  inflexibility  of  gradation  and  the  fact  that 
it  cannot  be  used  for  dark  adaptation, — or  over  wide  ranges  of  illumination, 
without  the  provision  of  many  gradations,  or  rings  of  gray  representing  the 
needed  differences  in  brightness  from  the  background.  It  is  also  fit  only 
for  the  determination  of  the  light  difference.  The  light  minimum  cannot 
be  determined  by  this  type  of  device.  The  determination  of  the  light  mini- 
mum should  be  made  in  the  dark  room,  and  in  the  strict  sense  of  the  term 
requires  a  fully  dark-adapted  eye. 

I  would  suggest  as  tests  for  the  use  of  the  British  Board  of  Trade  acuity 
at  low  illumination  and  speed  of  discrimination  both  of  the  acuity  object  and 
of  the  light  difference  at  low  illumination.  We  have  devised  and  used 
apparatus  for  making  these  determinations  and  have  found  them  to  be  of 
great  value  for  selecting  eyes  as  to  fitness  for  vocations  requiring  speed  and 
accuracy  of  seeing  at  low  illuminations.  Eyes  having  the  same  acuity  at 
high  illuminations  will  by  no  means  always  be  rated  as  equal  at  the  low  illu- 
minations and  the  scatter  is  very  much  greater  still  when  speed  is  added  to 
the  requirement  at  low  illumination.  Speed  and  power  to  sustain  are  aspects 
which  have  been  very  much  neglected  in  the  testing  of  acuity  and  other 
ocular  functions.  When  added  to  the  test  they  not  only  greatly  increase  its 
sensitivity,  but  take  account  of  functions  which  are  of  the  greatest  impor- 
tance to  the  working  eye.  Errors  in  refraction,  for  example,  which  cannot 
be  detected  by  the  conventional  method  of  testing  acuity,  show  plainly  in 
acuity  at  low  illumination,  and  in  speed  and  power  to  sustain  at  any  illu- 
mination, more  particularly  at  low  illumination.  While  these  extraordinary 
tests  may  not  at  this  time  be  considered  feasible  for  office  and  clinic  work, 
the  results  of  investigations  in  which  they  have  been  used  should  teach  us 
not  to  be  too  well  satisfied  with  our  present  standards  of  accomplishment  in 
the  detection  and  correction  of  defects. 

DR.  OTTO  ROELOFS  (Amsterdam,  Holland) :  I  was  surprised  at  hearing  that 
in  dark-adaptation  and  binocular  vision  there  is  a  summation  of  stimuli 
which  would  fail  by  light-adaptation.  This  conception,  first  defended  by 
Piper,  is  not  right.  Several  investigations,  principally  made  at  the  Univer- 
sity of  Amsterdam,  showed  that  this  summation  does  not  exist,  neither  by 
light-adaptation  nor  in  dark-adaptation.  The  phenomena  found  by  Piper 
are  the  results  of  a  fault  in  his  examination.  If  we  take  care  that  the  adapta- 
tion of  both  eyes  is  perfectly  equal  it  is  impossible  to  find  any  summation  of 
stimuli.  For  all  that  it  is  true  that  the  threshold  for  light-perception  (the 
light  minimum)  is  lower  by  binocular  vision  than  by  monocular  vision; 
this  fact  wants  another  explanation,  which  I  cannot  discuss  now  because  it 
would  take  too  much  time.  I  only  wish  to  mention  that  this  difference 
between  binocular  and  monocular  vision  can  be  found  as  well  by  light- 
adaptation  as  by  dark-adaptation.  These  results  are  confirmed  by  the 
investigations  of  Lehmann. 


476  ARCHIBALD  STANLEY  PERCIVAL 

I  want  to  ask  the  attention  to  the  connection  between  apparent  distur- 
bances in  the  sense  of  light  and  disturbances  in  the  field  of  vision,  and  I 
should  like  to  consider  the  possibility  that  a  disturbance  in  the  center  of  the 
field  of  vision  will  give  in  the  first  place  a  disturbance  of  the  light  difference, 
because  there  it  is  examined  by  more  light-adaptation,  and  that  a  disturbance 
in  the  periphery  of  the  field  of  vision  will  give  a  disturbance  of  the  light  mini- 
mum because  it  is  examined  by  more  ctarfc-adaptation. 

I  must  say  that  the  method  of  examination  does  not  satisfy  me.  We  always 
must  have  the  same  dark-  or  light-adaptation  as  a  starting  point  for  our 
examination  of  the  sense  of  light.  If  we  are  not  sure  that  at  the  beginning  of 
every  examination  the  dark-  or  light-adaptation  is  perfectly  the  same,  our 
results  cannot  be  of  any  significance.  Especially  I  am  surprised  that  a 
cataract  operation  can  be  refused  on  the  result  of  such  an  examination.  This 
method  of  examination  requires  not  only  a  certain  degree  of  sense  of  light, 
but  also  a  certain  degree  of  visual  acuity;  we  have  to  discern  the  several 
bands  on  the  rotating  disc.  An  opaque  lens  is  not  the  same  as  a  dark-tinted 
glass. 

COL.  R.  H.  ELLIOT  (London,  England) :  I  want  to  express  my  dissatis- 
faction with  the  present  state  of  our  knowledge  of  light-sense,  and  of  our 
tests  for  light-sense.  I  think  we  need  much  more  spade-work  before  we  can  be 
satisfied.  Both  the  central  and  peripheral  fields  require  to  be  tested.  We 
see  cases  of  glaucoma  obviously  suffering  from  a  deficient  light-sense  in  the 
peripheral  field,  and  yet  having  excellent  central  appreciation  both  of  light 
minimum  and  of  light  difference.  It  is  this  divergence,  or  apparent  diver- 
gence, of  my  experience  from  that  of  Mr.  Percival  and  others  that  has  led  me 
to  speak.  I  suggest  that  the  appreciation  of  light  by  the  glaucomatous  eye 
follows  the  variations  in  the  visual  field,  whether  central,  paracentral  or 
peripheral,  and  that  just  as  we  may  find  a  patient  with  good  central  vision, 
but  with  damage  to  his  paracentral  or  peripheral  visual  fields  or  both,  so  his 
light-sense  over  the  same  areas  may  be  affected.  Chronic  glaucoma  may 
be  expected  to  strike  first  at  the  paracentral  area,  and  next  at  the  periphery 
of  the  field.  Congestive  glaucoma  will  attack  the  whole  field  from  center  to 
periphery  in  light-sense,  just  as  it  does  in  the  other  functions  of  the  eye. 

My  preference  is  for  a  light-sense  apparatus  working  with  an  actual  light, 
and  Zeiss  has  made  one  such  for  me,  which  I  think  will  prove  satisfactory  for 
a  clinical  test  both  of  light  minimum  and  light  difference. 

Are  we  safe  in  neglecting  all  dark-adaptation  of  our  patient  in  advance? 
It  seems  doubtful,  and  I  think  we  need  expert  guidance  on  this  subject. 

DR.  ALEXANDER  DUANE  (New  York  City):  Mr.  Percival  in  his  paper 
reviews  some  elementary  principles  in  the  physiology  of  the  light-sense, 
calling  attention  especially  to  the  following  facts: 

1.  The  rods  are  particularly  associated  with  this  function. 

2.  Hence,  the  rod-free  portion  of  the  retina,  i.  e.,  the  fovea,  is  undersensitive 
to  differences  in  illumination,  and  therefore  when  the  illumination  is  consider- 
ably reduced  ceases  to  function,  so  that  a  central  scotoma  develops. 


Light-sense:  Simple  Tests  for  Determining  477 

3.  In  the  peripheral  portions  of  the  retina,  on  the  other  hand,  in  which  the 
form-sense  is  so  weak,  the  light-sense  is  strong.     It  reaches  its  maximum  in  a 
zone  some  10  degrees  out  from  the  fovea,  but  is  good  on  either  side  of  this 
zone.     It  is  hence  especially  important  in  determining  the   capacity  for 
peripheral  vision. 

4.  The  light-sense  is  the  most  primitive  of  the  retinal  functions  and  is 
hence  found  well  developed  in  conditions  in  which  the  form-sense  is  very 
deficient;  for  example,  in  strabismic  amblyopia.     Moreover,  in  normal  sub- 
jects it  is  well  retained  even  when  the  illumination  is  so  considerably  reduced 
that  the  form-sense  is  notably  impaired. 

5.  Some  of  our  so-called  form-sense  tests,  in  other  words,  tests  of  visual 
acuity,  are  really  in  part  tests  of  the  light-sense.     This  applies  to  the  ordinary 
letter  tests.     Failure  to  recognize  this  fact  has  led  to  some  erroneous  conclu- 
sions.    Thus  because  Prof.  Barnard  could  recognize  a  wire  against  the  sky  at 
a  distance  which  made  the  wire  subtend  an  angle  of  0.44  second,  it  was 
argued  that  this  represented  his  minimum  visual  angle,  which  would  mean 
that  his  visual  acuity  was  125  times  that  usually  regarded  as  normal.    As  a 
matter  of  fact,  however,  the  test  was  a  test  of  light-sense  only  and  no  more 
represented  a  test  of  visual  acuity  than  is  the  ability  to  distinguish  a  fixed 
star  which,  practically  speaking,  subtends  no  angle  at  all. 

Turning  from  these  theoretical  considerations  to  practical  points,  we  may 
make  the  following  statements : 

1.  The  tests  of  the  light-sense  are  important  clinically  in  two  regards:     (a) 
The  light-sense  being  concerned  especially  with  peripheral  vision  and  with  the 
discrimination  of  objects  affording  but  a  faint  contrast  with  their  surroundings 
it  is  important  that  it  should  be  systematically  examined  as  a  routine  matter 
in  those  who  in  their  avocations  have  to  discriminate  objects  situated  in  the 
periphery  of  the  field  and  but  faintly  visible.     It  is  important,  that  is,  to 
test  it  in  sailors,  particularly  in  lookouts  and  signalmen,  railroad  men,  chauf- 
feurs, aviators,  etc.     Of  its  great  significance  for  the  Army  and  Navy  service 
I  can  personally  testify.     (6)  The  test  is  important  in  determining  the  pres- 
ence of  diseases  of  the  sensory  apparatus  of  the  eye  and  in  discriminating 
between  different  affections  of  this  apparatus.     In  this  regard  we  must  note 
that  mere  opacities  of  the  media,  unless  very  dense,  do  not  greatly  diminish 
the  light-sense. 

2.  In  making  tests  of  the  light-sense  we  must  distinguish  between  the 
light  minimum  (LM)  and  the  light  difference  (LD).     The  former  is  meas- 
ured by  the  smallest  amount  of  light  that  can  be  distinguished  in  contrast 
with  darkness;  the  latter  by  the  smallest  difference  that  can  be  appreciated 
between  two  contrasting  light  stimuli. 

3.  The  light  difference  is  particularly  affected  in  diseases  of  the  conducting 
apparatus,  that  is,  the  optic  nerve  and,  according  to   Percival,  the  pro- 
longations of  the  latter  in  the  retina.  Lowered  light  difference,  therefore,  is 
found  in  optic  neuritis  and  atrophy,  retrobulbar  neuritis,  and  toxic  amblyopia ; 
probably  also  generally  in  affections  involving  specifically  the  superficial 
layers  of  the  retina.     The  light  minimum,  on  the  other  hand,  is  lessened  in 
choroidal  affections  and  in  the  deeper  forms  of  retinal  disease.     Percival  finds 
it  affected  quite  early  in  glaucoma,  the  light  difference  not  failing  until  later. 


478  ARCHIBALD  STANLEY  PERCIVAL 

4.  In  affections  of  the  media  so  dense  as  to  affect  the  light-sense,  both  light 
difference  and  light  minimum  fail  and  fail  equally.     Here  a  marked  dispro- 
portion between  the  two  in  the  case,  for  example,  of  a  cataract,  indicates  a 
disease  either  of  the  light-perceiving  or  light-conducting  apparatus — retina  or 
optic  nerve.     Percival  cites  an  interesting  case  of  cataract  in  which  he  declined 
to  operate  because  the  presence  of  such  a  disproportion  made  him  infer, 
correctly,  the  existence  of  a  macular  hemorrhage. 

5.  The  appliances  that  he  uses  for  testing  the  two  are  exceedingly  simple. 
They  have  the  great  advantage  that  they  do  not  require  a  long  preliminary 
period  of  dark-adaptation,  and  hence  can  be  used  by  daylight.     Moreover, 
the  examination  can  be  completed  in  one  or  two  minutes. 

6.  The  tests  themselves  are  simply  the  well-known  rotating  discs,  of  which 
the  Maxwell  disc  is  a  type.     Their  special  significance  consists  in  the  way 
they  are  graduated  so  as  to  indicate  the  normal,  or  definite  fractional  propor- 
tions of  the  normal.     The  test  for  the  light  minimum  consists  of  a  black  disc 
which  has  on  each  side  three  white  sectors.    The  innermost  sector  on  the  back 
surface  occupies  1  /12.5,  the  next  1  /25,  the  outermost  1  /50  of  the  ring  in 
which  it  is  contained.     On  the  front  surface  the  sectors  represent  similarly 
white  areas  of  1  /50,  1  /100  and  1  /200  of  the  corresponding  black  portion. 
The  light  difference  tests  are  precisely  similar,  but  the  sectors  here  are  black 
on  white  instead  of  white  on  black.     A  small  ratchet  rotatoV  worked  by 
thumb  pressure  is  used  for  spinning  the  discs  around. 

7.  When  the  light  minimum  disc  is  rotated  the  sectors  appear  as  grayish 
rings  on  a  black  ground.     The  normal  eye  should  distinguish  all  three  rings 
on  the  front  surface,  even  the  outermost.     The  light  minimum  then  equals 
1  /200  or,  as  Percival  more  conveniently  expresses  it,  200.     If  a  man  can 
distinguish  only  the  innermost  ring,  his  LM  is  50;  if  he  can  distinguish  no 
ring  on  the  front  surface  and  only  two  on  the  back,  his  LM  is  25. 

8.  A  similar  notation  obtains  for  the  LD  disc,  only  here  it  is  found  that 
very  few  people  can  recognize  more  than  two  rings  on  the  front  surface  of  the 
disc,  so  that  the  normal  LD  may  be  stated  as  100. 


SOME  CONTRIBUTIONS  TO  THE  SCIENCE  AND 
PRACTICE  OF  OPHTHALMOLOGY 

C.  E.  FERREE,  PH.D.,  AND  G.  RAND,  PH.D. 
Bryn  Mawr  College,  Bryn  Mawr,  Pa. 

I.  AN  ILLUMINATED  PERIMETER  WITH  CAMPIMETER  FEATURES1 
This  apparatus  was  devised  in  response  to  a  request  from  a  com- 
mittee appointed  by  the  American  Ophthalmological  Society  to  work 
out  a  better  standardization  of  the  illumination  of  perimeters  and  test 
charts.  The  request  was  for  a  feasible  means  of  illuminating  the 
perimeter  arm  with  light  of  a  good  intensity  and  quality,  so  that  every 
point  on  the  arm  in  any  meridian  in  which  it  may  be  placed  shall 
receive  equal  intensities  of  light.  Intensity  and  quality  of  illumina- 
tion, however,  are  only  two  of  the  factors  which  influence  the  results 
of  the  perimetric  determination.  In  devising  the  instrument  described 
in  this  paper  it  has  been  our  purpose  to  provide  a  control  also  of  other 
factors  which  are  of  importance  to  the  work  of  the  office  and  clinic. 
The  perimeter  to  be  described  in  this  paper  has  been  adopted  by  the 
committee  as  the  standard  instrument  for  office  and  clinic  work. 

The  variable  factors  which  influence  the  apparent  limits  of  color 
sensitivity  are,  so  far  as  we  have  been  able  to  discover,  the  wave- 
length and  purity  of  the  stimulus,  the  intensity  of  the  stimulus  and 
the  visual  angle,  length  of  exposure  of  the  eye,  the  method  of  exposure 
(moving  or  stationary  stimulus),  accuracy  and  steadiness  of  fixation, 
the  intensity  of  the  general  illumination  of  the  retina  and  its  state  of 
adaptation,  breadth  of  pupil,  and  the  brightness  of  the  pre-exposure 
and  of  the  background  or  surrounding  field.  The  most  important  of 
these  from  the  standpoint  of  the  office  or  clinic  are  perhaps  the  in- 
tensity of  the  stimulus,  the  brightness  of  the  pre-exposure  and  the 
surrounding  field,  the  intensity  of  the  general  illumination,  and  the 
accuracy  and  steadiness  of  fixation. 

Perhaps  errors  in  refraction  should  be  included  in  the  above  list  of 
factors.  They  differ  from  those  factors,  however,  in  that  they  are  a 
source  only,  or  mainly  at  least,  of  differences  in  breadth  of  field  between 

1  A  description  of  the  earliest  model  of  this  apparatus  appeared  in  Trans. 
Amer.  Ophthal.  Soc.,  1920,  172. 

479 


480  C.  E.  FERREE  AND  G.  RAND 

observers,  not  for  the  same  observer  at  different  times.  They  are  not, 
therefore,  a  serious  source  of  trouble  in  the  use  of  perimetry  to  check 
up  the  advance  or  recession  of  a  given  pathologic  condition,  but  they 
are  confusing  in  diagnosis.  We  have  no  certain  means  of  telling,  for 
example,  how  much  of  the  results  in  any  given  case  of  high  myopia  is 
due  to  the  refractive  condition  and  how  much  if  any  is  pathologic. 
To  add  to  our  knowledge  on  this  point  we  are  now  conducting  an  in- 
vestigation to  determine  the  effect  of  various  amounts  and  kinds  of 
refractive  errors  on  the  results  of  field  taking.  We  can  not  help  but 
feel,  as  is  stated  and  discussed  later  in  the  paper,  that  a  provision 
should  be  made  in  our  practice  of  field  taking  to  include  one  set  of 
results  under  correcting  glasses,  even  though  it  means  either  working 
under  conditions  which  give  a  narrow  field  or  being  content  with 
results  which  do  not  include  the  wider  portions  of  the  temporal  field. 

1.  INTENSITY  OF  STIMULUS. — By  a  sufficiently  wide  variation  of 
this  factor  alone,  the  zones  of  color  sensitivity  may  be  made  to  have 
almost  any  breadth  within  the  limits  of  the  field  of  vision,  to  differ 
radically  in  shape,  and  even  to  change  or  reverse  their  order  of  ranking 
as  to  breadth, — changes  of  a  type  and  magnitude  to  which  the 
clinician  might  ascribe  a  grave  and  important  pathologic  signifi- 
cance. Without  great  precision  in  the  control  of  intensity,  it  is  obvious 
that  reproducibility  or  result  can  not  be  obtained  and  little  diagnostic 
significance  can  be  attached  to  extent  or  shape  of  field,  to  order  of 
ranking  as  to  breadth  of  field,  or  to  any  variations  from  time  to  time 
or  from  person  to  person  in  these  important  features.  When  pigment 
surfaces  are  used  as  stimuli,  the  illumination  of  the  perimeter  arm  de- 
termines the  intensity  of  the  stimulus  light.  Two  methods  are  pro- 
posed for  securing  an  even  illumination  of  the  stimulus  at  every  point 
on  the  perimeter  arm  and  of  reproducing  this  illumination  froni  time 
to  time. 

Method  1. — When  the  source  of  light  is  inlaid  in  the  surface  of  the 
arm  or  its  continuation,  the  illumination  on  this  surface  will  be  equal 
for  approximately  180°  on  either  side  of  the  source.  The  value  of  this 
illumination  at  every  point  will  be  equal  to  the  normal  flux  of  light 
from  the  luminous  surface  divided  by  four  times  the  square  of  the 
radius  of  curvature  of  the  perimeter  arm,  or  four  times  the  square  of 
the  distance  of  the  eye  from  the  perimeter  arm.1  In  a  later  publica- 

1  For  a  discussion  of  the  principle  by  which  an  even  illumination  of  the  per- 
imeter arm  is  secured  by  this  method,  the  reader  is  referred  to  the  Trans.  Amer. 
Ophthal.  Soc.,  1920,  165-167. 


Contributions  to  the  Science  and  Practice  of  Ophthalmology     481 

tion  the  method  will  be  elaborated  and  a  perimeter  constructed  on  this 
principle  of  illumination  will  be  described.  This  type  of  device  is 
open  to  the  objections  of  being  difficult  of  construction  and  wasteful 
of  light. 

Method  2. — When  the  source  of  light  lies  in  the  perpendicular  to  the 
plane  of  the  perimeter  arm  at  its  center  of  curvature,  it  will  be  equi- 


Fig.  1 

distant  from  every  point  on  the  arm ;  also  the  angles  of  emission  and 
incidence  of  the  beam  of  light  will  be  equal  for  every  point  on  the  arm. 
A  perimeter  (Figs.  1  and  2)  has  been  constructed  embodying  this 
principle  of"  illumination.  Two  arcs  of  the  same  radius  of  curvature 
were  constructed  at  right  angles  to  each  other,  one  a  180°  arc,  the 
perimeter  arm ;  the  other  a  90°  arc,  the  lamp  arm,  at  the  end  of  which  is 
31 


482 


C.  E.  FERREE  AND  G.  RAND 


placed  the  source  of  light.  In  order  that  the  source  of  light  shall  sus- 
tain a  fixed  relation  to  the  perimeter  arm  for  all  positions  of  that  arm, 
the  two  arms  are  fastened  together  at  the  center  of  rotation.  About 
the  source  is  a  housing  which  is  designed  in  such  a  way  as  to  shield  the 
eye  of  both  patient  and  physician  without  interfering  with  the  dis- 


Fig.  2 

tribution  of  the  light  which  radiates  freely  from  the  filament  to  every 
point  on  the  perimeter  arm.  The  lamp  house  is  well  ventilated  and  the 
lower  part  is  hinged  to  provide  for  the  removal  of  the  lamp.  Pro- 
visions are  further  made  in  the  construction  of  the  lamp  house  for 
filtering  the  light  to  daylight  quality.  A  well-seasoned  type  C2  Mazda 
lamp  operated  by  ammeter  and  rheostat  control  is  used  as  the  source 


Contributions  to  the  Science  and  Practice  of  Ophthalmology     483 

of  light.  The  instrument  is  designed  to  run  on  any  110- volt  circuit. 
This  perimeter  is  not  difficult  to  construct  nor  to  operate.  It  provides 
for  a  uniform  illumination  of  the  perimeter  arm  in  all  meridians  with 
light  of  a  good  intensity  and  quality;  and  with  it  a  precision  of  con- 
trol is  possible  which  is  comparable  with  the  work  of  the  physical  lab- 
oratory. Of  the  two  instruments  we  have  constructed,  it  is  without 
doubt  much  the  more  feasible  and  it  is  also  very  probably  the  more 
correct  in  actual  practice.  Both  instruments  are  correct  in  theory. 

2.  THE  BRIGHTNESS  OF  THE  PRE-EXPOSURE  AND  THE  SURROUNDING 
FIELD. — The  brightness  of  the  surface  to  which  the  eye  is  pre-exposed 
may  change  the  apparent  limits  in  certain  meridians  as  much  as  17° 
to  20°.  A  pre-exposure  lighter  than  the  color  gives  a  dark,  and  one 
darker  than  the  color  a  light,  after-image.  These  after-images  change 
profoundly  the  saturation  of  the  color  sensation,  also  its  hue.  A  back- 
ground or  surrounding  field  lighter  or  darker  than  the  color  produces 
a  similar  effect  on  the  limits,  but  not  so  great.  In  this  case,  the  dis- 
turbing achromatic  effect  is  due  to  physiologic  induction  or  con- 
trast. The  variable  effect  of  brightness  of  pre-exposure  and  surround- 
ing field  can  be  eliminated  only  by  making  both  a  gray  of  the  same 
brightness  as  the  stimulus  color.  Here  again  a  precise  control  of  the 
intensity  of  the  illumination  for  all  points  on  the  perimeter  arm  be- 
comes important.  That  is,  the  shade  of  gray  which  is  needed  to  match 
the  color  in  brightness  changes  with  change  of  illumination;  there- 
fore, the  selection  of  a  gray  which  will  match  the  color  in  brightness 
for  all  points  of  work  presupposes  constancy  and  uniformity  of  il- 
lumination. A  further  advantage  is  gained  by  making  the  background 
of  the  same  brightness  as  the  color.  That  is,  when  color  and  back- 
ground are  of  the  same  brightness  the  stimulus  disappears  completely 
when  the  limit  of  sensitivity  to  that  color  is  reached,  instead  of  turning 
into  a  gray  concerning  the  colorlessness  of  which  the  patient  is  apt  to 
be  in  doubt.  This  gives  the  effect  of  the  disappearance  type  of  photom- 
eter and  like  it  adds  greatly  to  the  ease  and  certainty  of  making  the 
judgment. 

For  the  control  of  brightness  of  pre-exposure  and  surrounding  field 
cards  are  provided  covered  on  one  side  respectively  by  grays  of  trie 
brightness  of  the  colors  to  be  used  as  seen  in  the  peripheral  retina.  At 
the  center  of  each  of  these  cards  is  pasted  a  disc  of  the  appropriate 
color  subtending  a  visual  angle  of  1°.  To  provide  for  the  control  of 
the  pre-exposure  for  the  stationary  method  of  giving  the  stimulation, 
cards  identical  with  the  background  cards  are  provided,  covered  also 


484  C.  E.  FERREE  AND  G.  RAND 

on  one  side  with  a  gray  of  the  brightness  of  the  color.  The  stimulation 
by  this  method  is  given  as  follows :  The  stimulus  is  placed  at  the  point 
to  be  tested  and  covered  with  the  pre-exposure  card.  The  observer  is 
told  to  take  his  fixation.  At  a  given  signal  the  stimulus  is  uncovered 
for  one  second  and  recovered.  In  case  the  moving  stimulus  method  is 
used,  the  surrounding  field  serves  as  the  pre-exposure. 

3.  THE  ACCURACY  AND  STEADINESS  OF  FIXATION. — All  are  familiar 
with  the  disturbing  effect  of  inaccuracy  and  unsteadiness  of  fixation. 
If  correct  and  reproducible  results  are  to  be  obtained,  the  eye  must  be 
accurately  placed  at  the  center  of  the  sphere  in  the  surface  of  which 
lies  the  perimeter  arm,  and  the  line  of  sight  must  not  shift  from  the 
fixation  point  while  the  color  observation  is  being  made.  As  an  aid 
to  the  correct  placement  of  the  eye  and  a  check  on  its  steadiness  of 
fixation,  two  devices  have  been  provided : 

1 .  A  small  circular  mirror  is  used  as  a  fixation  object  in  which  the  ob- 
server sees  the  image  of  his  own  eye.1  When  the  eye  is  correctly 
placed  with  the  line  of  sight  normal  to  the  surface  of  the  mirror  at  its 
central  point,  the  fact  is  indicated  to  the  observer  by  the  position  of 
the  image  of  his  pupil  and  iris  as  seen  in  the  mirror.  Not  only  is  this 
simple  device  of  service  in  determining  the  correct  position  of  the  eye. 
but  it  aids  the  observer  greatly  in  holding  a  steady  fixation  by  giving 
him  an  immediate  indication  of  deviations  in  the  line  of  regard. 

We  scarcely  need  to  point  out  that  the  ordinary  fixation  object  does 
not  afford  an  accurate  control  of  fixation.  Exact  checking  methods 
show  that  the  observer  is  not  always  fixing  the  object  when  he  thinks 
he  is.  The  only  guide  to  monocular  fixation  is  clearness  of  seeing  and 
this  is  a  criterion  that  presents  considerable  latitude.  However,  with 
a  mirror  the  observer  has  an  objective  check  on  the  position  of  his  eye. 

One  of  the  objections  to  the  use  of  a  mirror  as  a  means  of  controlling 
fixation  is  the  liability  of  glare  from  its  surface,  probably  due  to  a  com- 
bined specular  and  diffuse  reflection  rendering  unnecessarily  difficult 
the  clear  seeing  of  the  eye  by  the  observer.  This  objection  has  been 
obviated  in  our  instrument  by  cutting  off  from  the  mirror  the  direct 
radiations  from  the  lamp  by  a  narrow  shield  which  can  be  turned  back 
out  of  the  way  when  not  in  use.  With  the  shield  in  position  the  eye 
receives  from  the  mirror  only  the  light  which  is  first  reflected  from  the 
eye  to  the  mirror  and  then  back  to  the  eye.  The  elimination  of  the 
troublesome  glare  from  the  surface  of  the  mirror  is  rendered  particu- 

1  For  a  cut  of  the  perimeter  furnished  with  this  fixation  device,  see  Trans. 
Amer.  Ophthal.  Soc.,  1920,  167. 


Contributions  to  the  Science  and  Practice  of  Ophthalmology     485 

larly  simple  and  easy  in  case  of  our  instrument  because  of  the  plan  of 
illumination  employed,  i.  e.,  the  light  all  comes  from  a  fixed  source 
above  and  directly  in  front  of  the  mirror. 

2.  The  second  device  for  the  control  of  fixation  is  similar  in  principle 
to  a  peep-sight  and  may  be  called  a  parallax  or  peep-sight  device.  A 
small  disc  placed  at  the  center  of  rotation  of  the  perimeter  arm  is 
viewed  through  a  circular  opening  in  a  small  metal  plate.  The  plane 
of  both  disc  and  opening  is  normal  to  the  line  of  sight  when  the  eye 
has  the  correct  position  and  fixation.  When  the  eye  has  this  position 
and  fixation  the  relation  of  size  of  disc  and  opening  is  such  that  the 
disc  is  seen  not  quite  to  fill  the  opening.  The  disc  is  painted  black, 
also  the  edge  of  the  opening,  thus  when  the  eye  has  the  proper  position 
and  fixation,  the  edge  of  the  opening  is  seen  concentric  to  the  disc  with 
a  narrow  ring  of  the  gray  of  the  perimeter  arm  between.  The  control 
afforded  by  this  device  is  very  sensitive.  A  very  slight  deviation  of 
the  position  or  fixation  of  the  eye  results  in  the  complete  or  partial 
extinction  of  this  gray  ring  at  a  point  in  the  direction  of  the  deviation. 

In  order  to  locate  the  eye  at  the  correct  distance  from  the  fixation 
object  a  light  measuring  rod  33  cm.  in  length  is  provided,  to  one  end  of 
which  is  fastened  a  small  metal  disc.  In  making  the  adjustment  for 
distance  one  end  of  the  rod  is  placed  against  the  fixation  object  at  its 
center  and  the  distance  of  the  perimeter  from  the  observer's  eye  is 
changed  by  means  of  a  coarse  screw  adjustment  until  the  closed  lid  is 
just  in  contact  with  the  metal  disc. 

A  final  important  feature  in  the  correct  adjustment  of  the  eye  is  to 
insure  a  constancy  of  relation  of  the  meridians  of  the  retina  to  the 
meridians  of  the  field  of  vision  as  laid  off  by  the  perimeter  arm;  in 
other  words,  to  guard  against  a  slight  tilting  of  the  head  to  one  side  or 
the  other.  For  this  purpose  we  have  designed  a  very  small  and  unob- 
jectionable mouth  bit  of  light  wood  (Fig.  1)  to  be  changed  for  each 
observer,  so  shaped  that  it  can  not  be  bitten  too  far  forward  or  back, 
and  thus  the  distance  of  the  eye  from  the  mirror  be  changed,  or  too 
far  to  one  side  or  the  other.  There  seems,  however,  to  be  an  insuper- 
able prejudice  against  the  use  of  a  mouth  bit  by  both  the  physician 
and  the  patient.  We  have  therefore  designed  a  head  rest  (Fig.  2) 
which  follows  approximately  the  outlines  of  the  forehead,  side  of  the 
head  and  face,  furnished  with  a  suitably  cupped  chin  rest  the  height 
of  which  is  adjustable.  To  provide  for  individual  differences  in  shape 
and  breadth  of  forehead,  an  adjustable  forehead  piece  or  band  of  thin 
spring  steel  extending  well  around  to  the  side  of  the  head  is  screwed  at 


486  C.  E.  FERREE  AND  G.  RAND 

its  central  point  to  the  forehead  piece  of  the  head  rest.  This  forehead 
band  is  adjusted  to  fit  foreheads  of  different  shape  and  breadth  by 
means  of  a  set  screw  on  either  side  near  the  two  ends  of  the  band. 
When  the  chin  rest  is  adjusted  to  its  proper  height  and  the  forehead 
band  is  made  to  fit  the  forehead,  the  patient's  head  is  held  com- 
fortably in  position  and  sufficiently  rigid,  it  is  believed,  to  satisfy  the 
needs  of  office  and  clinic  work.  At  least  the  probability  of  tilting 
the  head  to  one  side  or  the  other,  thus  causing  a  disagreement  of  the 
meridians  of  the  field  of  vision  as  indicated  by  the  perimeter  readings 
with  the  meridians  of  the  retina  is  very  greatly  lessened,  if  not  en- 
tirely obviated. 

In  order  to  quickly  and  conveniently  locate  the  patient's  eye  at  the 
center  of  the  perimeter  system  three  adjustments  are  provided:  a 
rack  and  pinion  to  raise  and  lower  the  head,  a  second  rack  and  pinion 
to  shift  the  head  to  right  or  left,  and  a  coarse  screw  adjustment  to 
change  the  distance  of  the  perimeter  arm  from  the  eye. 

A  very  great  practical  need  in  a  clinic  perimeter  is  a  method  of 
controlling  fixation  for  patients  who  have  a  central  scotoma  or  patho- 
logic blind  area.  With  the  eye  properly  adjusted  for  taking  the 
fields  these  patients  are  not  able  to  see  a  central  fixation  object.  We 
have  constructed  a  device  for  this  purpose  which  can  be  inserted  into 
the  hollow  axle  of  the  perimeter  in  place  of  the  mirror  or  the  peep 
sight.  This  device  consists  of  four  light  arms  at  right  angles  to  each 
other  curved  to  follow  the  arc  of  the  perimeter  arm,  and  of  sufficient 
breadth  to  provide  for  all  probable  breadths  of  scotoma.  Each  of 
these  arms  carries  a  small  stimulus,  the  distance  of  which  from  the 
center  of  the  field  is  adjustable.  In  adjusting  the  patient's  eye  the 
physician  looks  through  a  small  telescope  contained  in  the  hollow  axle 
and  lines  up  the  pupil  of  the  patient's  eye  with  the  cross  hair  in  the 
field  of  the  telescope.  If  desired  the  patient's  eye  can  be  made  more 
visible  by  reflecting  light  from  the  lamp  directly  on  it.  This  is  pro- 
vided for  (Fig.  1)  by  placing  a  small  oblong  mirror  of  specular  metal  on 
the  lamp  arm  at  such  a  position  and  angle  that  the  light  received  from 
the  lamp  will  be  reflected  on  the  iris.  This  mirror  is  hinged  to  the 
lamp  arm  and  can  be  turned  back  against  it  when  not  in  use.  When 
the  eye  is  observed  to  be  in  position,  the  four  stimuli  are  adjusted  so 
that  they  can  just  be  seen  by  the  patient  at  the  edges  of  the  scotoma. 
These  stimuli  serve  as  the  control  of  the  patient's  fixation,  his  instruc- 
tions being  so  to  direct  the  eye  that  all  are  visible. 

This  fixation  device  can  be  made  serviceable  for  mapping  the  sco- 


Contributions  to  the  Science  and  Practice  of  Ophthalmology     487 

toma  itself  by  adding  12  or  more  graduated  arms  equally  spaced,  pro- 
vided with  stimuli  similar  to  those  already  described  (Fig.  1).  Then 
when  the  fixation  is  obtained  by  the  adjustment  of  the  four  stimuli 
designed  for  that  purpose,  the  further  mapping  of  the  scotoma  is 
accomplished  by  moving  the  remaining  12  until  they  are  on  the  edges 
of  the  scotoma.  Or  if  preferred  the  physician  may  watch  the  patient's 
eye  through  the  telescope  directing  the  fixation  by  means  of  the  cross 
hairs,  while  all  of  the  stimuli  are  moved  into  position  on  the  edges  of 
the  blind  area.  This  objective  control  of  the  fixation  by  the  physician 
may  be  used,  if  desired,  both  in  mapping  the  scotoma  or  in  taking  the 
fields  when  a  central  scotoma  is  present. 

Another  important  need  in  a  clinic  perimeter  is  a  method  of  giving 
the  correct  location  and  fixation  to  eyes  suffering  with  high  myopia. 
Eyes  with  myopias  ranging  from  8  to  20  diopters  would  have  great 
difficulty  in  seeing  a  fixation  object  at  a  distance  of  33  cm.  Because  of 
the  grave  pathologic  changes  which  take  place  in  the  retina  and 
choroid  of  eyes  suffering  from  high  myopia,  particularly  in  the  region 
of  the  macula  and  nerve  head,  it  is  of  great  importance  to  be  able  to 
use  both  the  perimeter  and  tangent  screen  in  the  examination  of  eyes 
in  the  more  advanced  stages  of  myopia.  Three  provisions  have  been 
made  for  this:  (1)  The  mirror  may  be  mounted  on  a  rod  sufficiently 
long  to  permit  of  its  location  at  any  point  in  the  line  of  sight  between 
the  perimeter  arm  and  the  eye.  This  rod  may  be  inserted  into  the 
tubular  axle  on  which  the  perimeter  arm  rotates.  (2)  A  peep-sight 
device  is  provided  similar  in  principle  to  the  one  already  described  and 
so  constructed  that  it  may  suffice  as  a  fixation  control  for  values  of 
myopia  ranging  between  8  and  20  diopters.  And  (3)  the  perimeter 
arm  may  be  illuminated  with  two  intensities  of  light, — one  carrying 
the  fields  well  toward  the  periphery  of  the  retina;  the  other  giving 
limits  narrow  enough  to  fall  within  the  corrected  field  of  the  glasses 
which  are  worn  or  may  be  worn  by  the  patient.  This  feature  provides 
also  for  the  correction  of  high  astigmatisms  the  presence  of  which 
make  field  taking  annoying  and  uncertain  as  a  diagnostic  procedure. 
There  are  other  advantages  of  providing  for  the  taking  of  fields  at 
more  than  one  intensity  of  illumination :  (a)  Because  of  the  concentric 
arrangement  of  the  fibers  in  the  nerve  trunk  and  their  order  of  distri- 
bution in  the  retina,  it  may  be  of  importance  as  a  point  of  diagnosis  to 
sample  the  response  of  the  retina  at  different  degrees  of  eccentricity. 
And  (b)  the  low  illumination  fields  are  in  general  more  sensitive  to  the 
influence  of  the  pathologic  factors  which  cause  the  fields  to  have  dif- 


488  C.  E.  FERREE  AND  G.  RAND 

ferent  breadths.  This  is  in  part  due  to  the  fact  that  low  illumination 
fields  are  narrow  fields.  That  is,  sensitivity  falls  off  gradually  near  the 
center  of  the  retina,  therefore,  smaller  changes  of  sensitivity  are  re- 
quired near  the  center  of  the  retina  to  expand  or  contract  the  field.  It 
is  probably  also  due  in  part  to  the  change  produced  in  the  state  of  the 
retina's  sensitivity  at  the  low  illumination. 

The  control  of  fixation  for  the  presbyopic  eye  also  presents  a  prob- 
lem to  the  perimetrist.  The  eye  with  a  high  degree  of  presbyopia 
would  have  considerable  difficulty  in  seeing  with  the  necessary  clear- 
ness a  fixation  object  at  a  distance  of  33  cm.  By  the  use  of  the  mirror 
as  fixation  control  this  distance  is  extended  to  66  cm. ;  but  the  satis- 
factory use  of  the  mirror  requires  that  the  image  of  the  eye  be  seen 
fairly  clearly.  An  eye  without  power  of  accommodation,  even  if  there 
is  no  hyperopia  for  far  seeing,  is  approximately  1.50  diopters  out  of 
focus  for  an  object  at  a  distance  of  66  cm.  When  1.50  diopters  out  of 
focus  the  eye  can  not  see  its  image  in  the  mirror  with  a  satisfactory 
degree  of  clearness.  However,  the  mirror  can  be  used  with  a  fail- 
degree  of  satisfaction  for  lesser  degrees  of  presbyopia. 

We  have  three  proposals  to  make  for  the  control  of  fixation  for  the 
presbyopic  eye:  (1)  The  use  of  the  mrror,  if  desired,  for  the  lesser 
degrees  of  presbyopia.  (2)  The  use  of  an  illumination  sufficiently  low 
to  bring  the  color  fields  within  the  field  of  the  correcting  glasses. 
And  (3)  the  use  of  a  peep-sight  or  parallax  fixation  device  similar  in 
principle  to  the  one  already  described,  with  the  target  at  a  distance 
great  enough  to  be  seen  by  the  eye  without  power  of  accommodation.1 
Sixty-six  cm.  has  been  chosen  for  this  distance  because  (a)  the  target 
can  be  seen  at  66  cm.  with  sufficient  clearness  to  determine  whether  or 
not  it  is  at  the  center  of  the  viewing  opening,  formed  by  the  hollow 
axle  and  tube,  even  though  the  eye  is  as  much  as  1.50  diopters  out  of 
focus;  and  (b)  a  greater  distance  presents  difficulty  as  to  feasibility  of 
construction.  The  device  is  provided  also  with  a  lens  the  distance  of 
which  from  the  target  can  be  varied  from  its  focal  length  to  that  which 
is  needed  to  render  the  target  clearly  visible  at  66  cm.  This  lens  is 
mounted  in  the  end  of  a  short  tube  which  telescopes  to  the  desired 
depth  into  the  main  tube  at  the  end  facing  the  target.  By  suitably 
changing  the  distance  of  the  lens  from  the  target  the  apparent  distance 
of  the  target  can  be  made  to  have  any  value  between  6  m.  and  66  cm. 

1  As  already  stated,  the  device  for  control  of  fixation  in  high  degrees  of  myopia 
is  also  shown  in  Fig.  2  in  position  for  use.  When  using  either,  the  other  should,  of 
course,  be  removed. 


Contributions  to  the  Science  and  Practice  of  Ophthalmology     489 

By  means  of  this  optical  device,  therefore,  a  clear  image  of  the  target 
can  be  formed  on  the  retina  of  patients  having  all  possible  degrees  of 
presbyopia.  However,  as  we  have  already  stated,  it  is  quite  possible 
to  secure  a  good  control  of  fixation  for  any  degree  of  presbyopia  with- 
out the  use  of  the  optical  attachment. 

The  steadiness  of  fixation  is  greatly  influenced  by  the  method  of 
giving  the  stimulation.  One  of  the  serious  objections  to  a  moving 
stimulus  is  the  difficulty  of  holding  a  steady  fixation  while  the  object 
to  be  observed  is  moving.  The  alternative  procedure  is  the  use  of  a 
stationary  stimulus.  That  is,  the  stimulus  is  placed  at  the  desired 
point  on  the  perimeter  arm  and  covered  with  the  pre-exposure  card. 
The  observer  takes  his  fixation  and  at  a  given  signal  the  stimulus  is 
exposed  and  recovered.  By  this  method  of  giving  the  stimulation 
more  time  is  consumed  but  a  much  greater  precision  of  result  is  pos- 
sible. A  compromise  procedure  is  recommended.  That  is,  the  ap- 
proximate location  of  the  limit  is  determined  with  the  moving  stimulus 
and  the  exact  location  with  the  stationary  stimulus.  By  this  com- 
promise but  very  little  more  time  is  required  and  there  is  no  sacrifice 
of  precision. 

In  order  to  provide  for  the  mapping  of  the  normal  blind  spot  and 
for  the  quick  detection  and  mapping  of  central  and  paracentral  scoto- 
mata,  it  has  been  deemed  advisable  to  add  to  the  perimeter  a  tangent 
screen,  subtending  a  visual  angle  of  60  or  more  degrees.  Provision  is 
made  so  that  this  screen  can  be  quickly  and  conveniently  attached  to 
the  stimulus  carriage  and  moved  into  position.  The  stimulus  carriage 
and  the  tangent  screen  have  at  their  exact  center  a  circular  opening 
equal  in  size  to  the  cross-section  of  the  tubular  aperture  about  which 
the  perimeter  arm  rotates.  Thus  when  the  tangent  screen  is  in  posi- 
tion, i.  e.,  with  its  central  point  in  the  axis  of  rotation  of  the  perimeter 
arm,  the  tubular  opening  in  the  perimeter  is  continued  through  to  the 
front  surface  of  the  tangent  screen.  This  provides  both  for  the  exact 
adjustment  of  the  tangent  screen  and  permits  of  the  convenient  use 
with  it  of  all  of  the  fixation  controls  which  we  have  described.  Cards 
of  white  or  black,  as  may  be  desired,  with  the  fields  laid  off  on  the  tan- 
gent scale  are  provided  for  the  mapping  of  the  area  deficient  in  the 
light  sense,  and  of  grays  of  the  brightness  of  the  colors  for  mapping  the 
color  deficiencies. 

In  our  own  work  we  have  found  it  convenient  to  use  this  large  screen 
for  a  quick  survey  of  the  field  for  scotomata  and  a  smaller  screen 
similar  to  the  one  used  to  carry  the  colored  stimulus  in  the  field  taking 


490  C.  E.  FERREE  AND  G.  RAND 

for  the  actual  detailed  mapping  of  the  scotomata  and  the  normal 
blind  spot.  This  screen  was  made  considerably  larger  than  the  screens 
which  serve  as  backgrounds  for  the  colored  stimulus  in  field  taking  in 
order  that  it  might  serve  for  the  mapping  of  large  scotomata  and 
pathologically  enlarged  blind  spots.  It  is  mounted  in  a  carriage  of 
its  own  and  is  shaped  to  take  the  curvature  of  the  perimeter  arm.  This 
screen  is  intended  not  as  a  substitute  for  the  larger  screen  but  as  a 
supplement  in  cases  in  which  such  a  supplement  is  found  to  be  con- 
venient and  desirable.  This  device  has  the  following  advantages  over 
the  large  central  tangent  screen  for  the  actual  mapping  of  the  blind 
areas :  (1)  It  can  be  moved  to  any  part  of  the  field  from  the  center  out 
to  90°  in  any  meridian  and  its  center  located  at  the  center  of  the  area 
to  be  mapped.  When  the  screen  is  properly  centered  the  mapping  can 
be  done  as  it  is  on  any  tangent  screen.  (2)  Upon  each  screen  are 
drawn  sixteen  meridians  radially  from  the  center  of  the  screen.  These 
meridians  are  finely  graduated  so  that  the  limits  of  sensitivity  in  any 
meridian  can  be  read  off  for  the  permanent  record  and  transferred  to 
properly  planned  maps  at  the  convenience  of  the  experimeter.  (3) 
Blind  areas  are  most  easily  and  precisely  mapped  when  the  stimulus 
is  made  to  follow  lines  radiating  from  the  center  of  the  area.  Unless 
there  are  such  guiding  lines  it  is  difficult  to  pass  from  within  out  or 
from  without  in  consistently  when  determining  the  limits  of  the  blind 
area  or  when  checking  up  the  location  of  a  limit  by  a  second  or  third 
determination.  On  a  large  fixed  screen  these  lines  would  have  to  be 
drawn  specially  for  each  scotoma.  (4)  All  of  the  evidence  points 
toward  the  importance  of  mapping  the  blind  areas  with  colored 
stimuli — particularly  the  Mariotte  spot.  It  is  highly  important  that 
the  determinations  for  the  different  colors  be  made  on  backgrounds  of 
the  same  brightness  as  the  colors,  as  will  be  shown  by  blind  spot 
studies  to  be  published  later.  It  is  much  more  feasible  to  arrange  for 
this  in  case  of  the  smaller  movable  fields  than  in  case  of  a  large  fixed 
field.  When  the  background  for  the  smaller  field  is  laid  off  in  grad- 
uated radial  lines  it  can  serve  for  the  mapping  of  many  blind  spots  and 
scotomata  before  it  need  be  replaced.  In  case  of  a  large  fixed  screen, 
this  superior  adaptability  and  long  service  would  not  be  possible. 
(5)  With  the  movable  smaller  field  it  is  more  nearly  possible  to  map 
all  blind  areas  under  the  conditions  of  equal  illumination  which  ob- 
tains in  the  perimetry  of  the  color  fields  than  it  is  in  the  use  of  the 
large  fixed  screen.  In  the  latter  case  the  illumination  at  which  the 
mapping  is  done  in  one  part  of  the  field  may  be  quite  appreciably  dif- 


Contributions  to  the  Science  and  Practice  of  Ophthalmology     491 

ferent  from  that  at  which  it  is  done  in  another  part  of  the  field.  The 
control  of  illumination,  while  not  so  important  for  mapping  the  blind 
areas  to  the  light  sense  stimuli,  is  very  important  in  the  mapping  of 
the  blind  areas  to  color. 

With  the  controls  provided  in  the  perimeter  recommended,  a  care- 
ful worker  can  without  difficulty  reproduce  the  limits  of  sensitivity 
within  1  or  2  degrees. 

II.  VARIABLE  FACTORS  WHICH  INFLUENCE  THE  DETERMINATION  OF 
THE  COLOR  FIELDS 

We  have  already  given  a  list  of  the  variable  factors  which  influence 
the  apparent  limits  of  color  sensitivity  and  have  stated  that  the  most 
important  of  these  factors  from  the  standpoint  of  the  work  of  the  office 
and  clinic  are  perhaps  the  intensity  of  the  stimulus  and  the  precision 
of  its  control,  the  brightness  of  the  surrounding  field  and  of  the 
pre-exposure,  the  intensity  of  the  general  illumination,  and  the  accu- 
racy and  steadiness  of  fixation.  Space  can  be  taken  here  for  the  dis- 
cussion of  the  effect  of  intensity  alone.  Reference  will,  however,  be 
given  to  discussions  and  data  bearing  on  the  other  factors.1 

INTENSITY  OF  STIMULUS. — By  a  sufficiently  wide  variation  of  this 
factor  alone  the  fields  of  color  sensitivity  may  be  made  to  have  almost 
any  breadth  within  the  field  of  vision,  to  differ  radically  in  shape,  and 
even  to  change  or  reverse  their  order  of  ranking  with  regard  to 
breadth.  For  example,  with  very  high  intensities  the  limits  of  red, 
yellow  and  blue  are  coincident  with  the  limits  of  white  light  vision. 
Green  can  not  be  made  to  have  so  wide  an  extent;.  With  stimuli  of 
medium  intensity  and  of  the  relative  energies  found  in  the  prismatic 
spectrum  of  a  Nernst  filament  the  limits  are  concentric  and  in  the 
order  from  widest  to  narrowest  of  red,  yellow,  blue  and  green.  With 
stimuli  of  medium  intensities  of  equal  energy  the  limits  of  red,  yellow 
and  blue  interlace  or  crisscross.  The  limits  for  green  again  are  nar- 
rower. The  limits  for  pigment  stimuli  may  be  either  interlacing,  or 
concentric  in  the  order  of  widest  to  narrowest  of  red,  blue  and  green ; 

1  The  Factors  that  Influence  the  Sensitivity  of  the  Retina  to  Color.  A  Quanti- 
tative Study  and  Methods  of  Standardizing,  Psych.  Rev.  Monog.,  1913, 
xv  (1),  178;  Factors  Which  Influence  the  Color  Sensitivity  of  the  Peripheral 
Retina,  Trans.  Amer.  Ophthal.  Soc.,  1920;  The  Extent  and  Shape  of  the  Zones  of 
Color  Sensitivity  in  Relation  to  the  Intensity  of  the  Stimulus  Light,  Amer.  Jour. 
Physiol.  Optics,  1920,  i,  185-213;  The  Limits  of  Color  Sensitivity:  Effect  of 
Brightness  of  Pre-exposure  and  Surrounding  Field,  Psych.  Rev.,  1920,  xxvii, 
377-398. 


492  C.  E.  FERREE  AND  G.  RAND 

or  of  blue,  red  and  green  depending  upon  the  pigments  used  and  the 
intensity  of  light  falling  on  the  perimeter  arm.  It  seems  only  fair  to 
conclude,  therefore,  that  the  conventional  clinic  rating  of  the  limits 
from  widest  to  narrowest  in  the  order  of  blue,  red  and  green  is  a  func- 
tion of  the  relative  and  absolute  intensity  of  the  stimuli  employed  as 
well  as  of  the  actual  distribution  of  sensitivities.  A  change  in  the 
intensity  of  the  stimulus  not  only  changes  the  limits  but,  because  of 
the  irregular  distribution  of  sensitivities  in  the  different  meridians, 
causes  a  marked  change  in  the  shape  of  the  fields;  and  because  of 
changes  in  the  ratio  of  sensitivity  to  the  different  colors  in  the  same 
meridians,  a  change  in  their  ranking  as  to  breadth.  Without  great 
precision  in  the  control  of  intensity,  it  is  obvious  thatreproducibility  of 
result  can  not  be  obtained  and  little  significance  can  be  attached  to 
extent  or  shape  of  field,  to  order  of  ranking  as  to  breadth  of  field,  or  to 
any  variations  from  time  to  time  or  from  person  to  person  in  these 
important  features. 

The  effect  of  changes  in  the  intensity  of  the  stimulus  both  on  the 
extent  and  shape  of  the  color  fields  varies  with  the  order  of  magnitude 
of  intensity  employed.  For  medium  and  low  intensities  the  effect  of  a 
given  amount  of  change  is  very  much  greater  than  for  high  intensities. 
This  is  an  obvious  corollary  of  the  type  of  distribution  of  sensitivities 
found  in  the  peripheral  retina.  That  is,  in  passing  from  the  center 
toward  the  periphery  of  the  retina  the  decrease  in  sensitivity  is  com- 
paratively slow  and  gradual  in  the  paracentral  retina;  it  is  much 
faster  and  more  abrupt  in  the  mid  periphery;  and  very  abrupt  in  the 
far  periphery.  It  requires,  therefore,  comparatively  large  changes  in 
stimuli  of  high  intensity  which  carry  the  limits  of  sensitivity  into  the 
far  periphery,  to  produce  a  significant  change  in  the  fields;  not  so 
great  a  change  in  stimuli  of  medium  intensity;  and  a  still  smaller 
change  in  stimuli  of  low  intensity.  This  effect  varies  greatly,  however, 
for  the  same  color  in  the  different  meridians  and  for  different  colors  in 
the  same  meridian.  For  stimuli  of  the  medium  and  low  intensities 
used  in  the  office  and  clinic,  the  effect  of  change  of  intensity  is  very 
marked  indeed  both  on  the  extent  and  shape  of  the  fields  of  sensitivity. 

We  have  stated  that  the  order  in  which  the  fields  may  be  found  to 
occur  ranked  with  regard  to  breadth  depends  both  upon  the  actual 
distribution  of  sensitivities,  and  upon  the  relative  and  absolute  in- 
tensities of  the  stimuli  employed.  That  it  depends  upon  the  relative 
intensities  of  the  stimuli  employed  should  be  more  or  less  obvious, 
provided,  of  course,  that  the  relative  differences  of  intensity  are  great 


Contributions  to  the  Science  and  Practice  of  Ophthalmology     493 


enough  to  overcome  or  reverse  actual  differences  in  sensitivity.  In 
support  of  the  statement  that  it  depends  also  on  the  absolute  intensity, 
maps  will  be  shown  in  which  for  the  same  eye  and  a  constant  ratio  of 
intensity  of  stimuli,  the  limits  for  red  and  blue  in  some  cases  interlace 
or  crisscross;  in  others  they  are  concentric  or  nearly  so,  the  limits  for 
blue  lying  outside  of  the  limits  for  red  or  conversely  the  limits  for  red 
lying  outside  of  the  limits  for  blue, — the  difference  in  result  depending 
solely  upon  the  absolute  intensities  of  the  stimuli  employed.  The 


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Fig.  3. — Chromatic  thresholds  for  the      Fig.   4. — Chromatic  thresholds  for  the 
four  colors,  temporal  meridian.  four  colors,  nasal  meridian. 

determinations  were  made  with  the  Hering  standard  pigments  pre- 
sented to  the  eye  by  means  of  the  perimeter  just  described,  with  the 
pre-exposure  and  surrounding  field  of  the  brightness  of  the  color,  the 
only  variable  being  the  intensity  of  illumination  of  the  perimeter  arm. 
The  effect  of  such  factors  as  intensity  on  the  extent  and  shape  of  the 
color  fields  and  their  order  of  ranking  as  to  breadth  can  be  better 
understood  when  a  thorough  knowledge  is  had  of  the  actual  distribu- 
tion of  sensitivities  from  point  to  point  from  center  to  periphery  of 


494 


C.  E.  FERREE  AND  G.  RAND 


the  retina.  In  order  to  show  this  distribution  of  sensitivity  from  cen- 
ter to  periphery  of  the  retina  we  have  made  determinations  of  the 
threshold  of  sensation  (the  amount  of  light  required  just  to  arouse  the 
color  sensation)  with  spectrum  lights  and  under  proper  conditions  of 
control  for  the  different  colors  at  near  lying  points  in  the  different 
meridians.  A  graphic  representation  of  the  results  of  these  determi- 
nations for  two  meridians,  the  temporal  and  nasal,  is  given  in  Figs. 


Fig.  5. — Chromatic  thresholds  (en- 
larged scale)  for  the  four  colors,  tem- 
poral meridian. 


Fig.  6. — Chromatic  thresholds  (en- 
larged scale)  for  the  four  colors,  nasal 
meridian. 


3  to  6.  In  these  curves  the  degree  of  eccentricity  is  plotted  along  the 
horizontal  co-ordinate  and  the  energy  or  intensity  values  of  the 
threshold  in  watts  (107  ergs  per  second)  are  plotted  along  the  vertical 
co-ordinate.  Maps  have  been  made  also  showing  the  effect  of  varying 
the  intensity  of  the  stimulus  on  the  breadth,  shape,  and  order  of  rank- 
ing of  the  color  fields  as  to  breadth  in  sixteen  meridians.  Two  sets  of 
conditions  have  been  used:  high  intensities,  the  fields  having  been 
taken  with  our  rotary  campimeter  and  spectrum  lights;  and  medium 


Contributions  to  the  Science  and  Practice  of  Ophthalmology     495 

and  low  intensities,  the  fields  having  been  taken  with  the  perimeter 
described  in  the  preceding  section  and  pigment  stimuli.  Space  will  be 
taken  here  for  a  representation  only  of  the  results  obtained  under  the 
second  set  of  conditions.1 

In  this  second  series  of  determinations  five  intensities  of  light 
reflected  from  pigment  stimuli  were  used:  the  Hering  standard  pig- 
ments under  51,  17,  7,  3  and  0.03  foot-candles  of  light.  In  order  to 
show  how  these  illuminations  compared  with  the  day-light  illumina- 
tion falling  on  the  perimeter  arm  in  an  ordinary  room,  measurements 
were  made  of  the  daylight  at  the  level  of  the  perimeter  in  a  room  with 
a  window,  southern  exposure,  the  lower  sill  of  which  was  somewhat 
higher  than  the  level  of  the  perimeter  arm  placed  in  the  horizontal. 
These  measurements  were  made  on  a  bright  day,  January  14, 1921.  It 
was  found  that  our  highest  intensity  of  illumination,  51  foot-candles, 
was  the  same  as  that  falling  on  the  perimeter  arm  at  the  fixation  point 
when  facing  the  window  at  1  p.  M.  ;  our  second  highest  illumination, 
17  f .  c.,  was  the  same  as  that  falling  at  the  fixation  point  at  2.30  P.  M.  ; 
the  third  highest  illumination,  7  f.  c.,  the  same  as  that  falling  on  the 
fixation  point  at  3.45  p.  M.  ;  and  the  fourth,  3  f.  c.,  the  same  as  that 
falling  on  the  fixation  point  at  4.15  P.  M.  Measurements  were  also 
made  with  the  perimeter  placed  parallel  to  the  window.  Our  second 
illumination,  17  f.  c.,  was  the  same  as  that  falling  on  the  fixation  point 
at  11  A.  M.;  the  7  f.  c.  illumination,  at  1.30  P.  M.;  and  the  3  f.  c. 
illumination,  at  2.30  P.  M. 

The  decrease  of  illumination  from  51  to  3  foot-candles  narrowed  the 
limits  for  red  by  an  amount  ranging  from  11  to  37  degrees;  blue,  13  to 
37  degrees;  and  green  10  to  19  degrees,  a  result,  it  will  be  remembered, 
which  was  produced  by  a  change  of  illumination  equal  to  that  which 
occurred  from  1  to  4.15  P.  M.  in  a  well-lighted  room  on  a  bright  winter 
day.  The  decrease  of  illumination  from  51  to  0.03  foot-candles  nar- 
rowed the  limits  for  red  by  an  amount  varying  from  27  to  72  degrees ; 
blue,  29  to  61  degrees;  and  green,  22  to  45  degrees  (Figs.  7  to  13). 

Since  this  perimeter,  with  its  pigment  stimuli  different  from  those 
now  in  use  in  office  and  clinic  work,  and  its  standardization  and  con- 
trol of  factors,  introduces  a  new  situation  in  perimetry,  it  becomes 

1  For  the  results  for  the  first  set  of  conditions,  the  reader  is  referred  to  The 
Extent  and  Shape  of  the  Zones  of  Color  Sensitivity  in  Relation  to  the  Intensity 
of  the  Stimulus  Light,  Amer.  Jour.  Physiol.  Optics,  1920,  i,  185-213;  Factors 
Which  Influence  the  Color  Sensitivity  of  the  Peripheral  Retina,  Trans.  Amer. 
Ophthal.  Soc.,  1920;  The  Absolute  Limits  of  Color  Sensitivity  and  the  Effect  of 
Intensity  of  Light  on  the  Apparent  Limits,  Psych.  Rev.,  1920,  xxvii,  1-23. 


496 


C.  E.  FERREE  AND  G.  RAND 


necessary  to  determine  a  norm  for  the  color  fields  under  the  new  con- 
ditions to  serve  as  a  standard  or  basis  for  comparisons.    This  work  is  in 


Fig.  7. — Fields  taken  under  51  foot- 
candles  of  light,  an  illumination  equal 
to  the  daylight  falling  on  the  perimeter 
at  the  fixation  point  when  facing  a 
window  on  a  bright  day,  1  P.  M. 


Fig.  8. — Fields  taken  under  17  foot- 
candles  of  light,  an  illumination  equal 
to  the  daylight  at  the  fixation  point, 
perimeter  facing  a  window  on  a  bright 
day,  2.30  P.  M.,  or  at  11  A.  M.,  perim- 
eter parallel  to  window. 


Fig.  9. — Fields  taken  under  7  foot- 
candles  of  light,  and  illumination  equal 
to  the  daylight  at  the  fixation  point, 
perimeter  facing  a  window  on  a  bright 
day,  at  3.45  P.  M.,  or  at  1.30  p.  M., 
perimeter  parallel  to  window. 


Fig.  10. — Fields  taken  under  3  foot- 
candles  of  light,  an  illumination  equal 
to  the  daylight  at  the  fixation  point, 

Serimeter  facing  a  window  on  a  bright 
ay  at  4.15  p.  M.,  or  at   2.30  p.  M., 
perimeter  parallel  to  window. 


progress  but  has  not  yet  been  finished.    Average  fields  for  blue,  red, 
and  green  have  been  determined  for  35  normal  observers  just  as  the 


Contributions  to  the  Science  and  Practice  of  Ophthalmology     497 

perimeter  stands,  i.  e.,  with  17  foot-candles  of  light  on  the  test  object 
and  with  the  controls  described  (Fig.  11).  As  fast  as  possible  studies 
will  be  made  also  of  typical  pathologic  cases, — also  of  normal  and 


Average  color  fields 
Fig.  11. — Fields  for   blue,  red,  and 
green,  for  35  normal  observers. 


Fields  for  blue 

Fig.  12. — Showing  variations  in  both 
the  extent  and  the  shape  of  the  color 
fields  when  taken  under  51,  17,  7,  3, 
and  0.03  foot-candles  of  light. 


Fields  for  red  Fields  for  green 

Fig.  13.— Showing  variations  in  both  the  extent  and  the  shape  of  the  color  fields 
when  taken  under  51,  17,  7,  3,  and  0.03  foot-candles  of  light 

pathologic  cases  at  a  suitably  selected  lower  illumination.  An  other 
feature  of  the  advance  work  will  be  to  ascertain  how  far  if  at  all  the 
determination  of  central  sensitivity  can  be  substituted  for  field  taking 
32 


498  C.  E.  FERREE  AND  G.  RAND 

in  the  diagnosis  of  pathologic  conditions;  and  how  valuable  as  a 
supplement  such  determinations  are  in  a  diagnostic  program.  The 
quickness  and  the  superior  ease  and  precision  with  which  the  determi- 
nation of  central  sensitivity  can  be  made  are  strong  points  in  favor  of 
its  use  in  practical  work.  A  further  advantage  is  that  the  determi- 
nation can  be  readily  made  with  the  eye  corrected  for  defects  in 
refraction. 

III.  THE  ACUITY  LANTERN 

This  apparatus  was  devised  in  response  to  a  request  by  the  Eye 
Division  of  the  U.  S.  Naval  Hospital  for  a  means  of  making  a  quick 
and  accurate  test  of  acuity  at  low  illumination.  Experience  has  shown, 
roughly  speaking,  that  only  25  to  30  per  cent,  of  the  men  on  the  battle- 
ships have  a  sufficiently  keen  acuity  at  low  illuminations  to  qualify 
for  all  branches  of  the  lookout  and  signal  service  work.  The  apparatus 
provides  for  a  wide  range  of  illumination  in  just  noticeably  different 
steps  (beginning  at  0.07  meter-candle  or  lower)  with  no  change  in  the 
color  value  of  the  light  and  with  a  specification  at  each  step  of  the 
intensity  of  light  falling  on  the  test-object. 

For  use  in  laboratory  and  clinic  work  the  original  apparatus  has 
been  elaborated  to  serve  the  following  purposes :  (a)  for  testing  acuity 
with  a  means  of  varying,  controlling  and  specifying  the  amounts  of 
light  used  over  a  wide  range  of  intensity  of  illumination;  (b)  for  de- 
termining the  exact  amount  and  location  of  an  astigmatism  with 
great  delicacy  and  precision  and  for  using  at  will  either  the  visual 
angle  or  the  illumination  scale  for  the  detection  of  errors  in  refraction 
or  in  their  correction;  (c)  for  testing  the  light  and  color  sense  in 
terms  of  the  amount  of  light  required  just  to  arouse  the  light  and 
color  sensations;  and  (d)  for  varying  independently  the  saturation  and 
brightness  of  a  color  and  for  color  mixing. 

Among  the  requirements  for  an  apparatus  for  determining  acuity  at 
low  illuminations  or  the  effect  of  change  of  illumination,  the  following 
points  may  be  mentioned:  (1)  A  means  of  changing  the  illumination 
by  small  amounts  over  a  wide  range,  beginning  at  or  below  the  thres- 
hold for  the  test-object  employed,  without  changing  the  color  value  of 
the  light.  If  in  making  this  change  the  color  value  of  the  light  is 
altered  it  is  obvious  that  another  factor  affecting  the  results  is  intro- 
duced. (2)  A  means  of  keeping  constant  for  an  indefinite  length  of 
time  any  desired  intensity  of  illumination  and  of  reproducing  this 
intensity  at  will.  (3)  A  means  of  specifying  accurately  at  any  point  in 


Contributions  to  the  Science  and  Practice  of  Ophthalmology     499 

the  scale  the  intensity  of  light  falling  on  the  test-object;  and  (4) 
it  is  desirable  that  the  apparatus  employed  for  controlling  the  illumi- 
nation can  be  used  with  the  test-objects  already  accepted  in  clinic 
practice. 

The  most  difficult  problem  one  has  to  face  in  constructing  an  appa- 
ratus for  determining  the  minimum  amount  of  light  that  permits  of 
the  discrimination  of  a  given  test-object,  more  particularly  if  that 
object  consists  of  a  line  of  test  letters,  is  to  secure  a  uniform  illumina- 
tion of  the  line.  We  were  able  satisfactorily  to  meet  this  difficulty  in 
only  one  way,  namely,  by  selecting  an  aperture  sufficiently  small  to 
permit  of  its  uniform  illumination  and  projecting  a  magnified  image  of 
this  aperture  on  the  test  card.  That  is,  an  aperture  was  selected  of 
such  a  size  and  shape  that  when  magnified  five-fold  it  gave  a  band  of 
light  which  just  blocked  off  one  line  of  the  test  letters.  It  is  obvious 
that  this  aperture  could  be  made  of  different  sizes  and  shapes  depend- 
ing upon  what  is  wanted  in  the  projected  image.  For  example,  two  or 
three  lines  of  test  letters  could  be  blocked  off  if  desired,  or  the  whole 
card  or  any  part  of  it  could  be  illuminated,  etc.  There  is  no  reason, 
moreover,  why  the  aperture  could  not  be  made  adjustable  in  size  to 
suit  the  needs  and  preferences  of  the  individual  operator.  In  one 
model  of  the  apparatus  these  apertures  were  cut  in  a  series  of  slides 
which  could  be  inserted  in  the  projection  tube  just  outside  the  lamp 
house  in  grooves  in  a  light-tight  boxing.  A  convenient  means  was 
thus  provided  for  changing  the  aperture,  if  desired,  during  a  series  of 
tests  without  having  to  open  the  lamp  house.  The  source  of  light  is  a 
well-seasoned  Mazda  C  lamp  of  the  round  bulb  or  stereopticon  type 
of  100,  250  or  500  watts,  depending  upon  the  range  of  illumination  that 
is  desired.  The  lamp  is  installed  vertically  in  the  roof  of  the  lamp 
house  at  such  a  height  that  its  filament  is  well  above  the  aperture 
which  is  to  be  illuminated.  In  order  to  secure  a  uniform  and  diffuse 
illumination  of  the  aperture  the  lamp  house  is  lined  with  opal  glass 
ground  on  one  side.  The  aperture,  6x1  cm.,  is  cut  at  the  center  of 
the  cap  covering  the  inner  end  of  the  projection  tube.  Further  to  aid 
in  the  even  illumination  of  the  aperture  it  is  covered  with  a  slide  of 
ground  glass.  The  changes  in  the  intensity  of  light  are  produced  by 
means  of  an  iris  diaphragm.  When  such  a  diaphragm  is  placed  either 
at  the  front  or  back  surface  of  the  focusing  lens,  changes  in  the  flux 
of  light  can  be  produced  without  any  alteration  in  the  size  or  the  shape 
of  the  image  produced  by  the  lens,  just  as  happens,  for  example,  in 
the  action  of  the  iris  of  the  eye.  At  a  suitable  point  in  the  circum- 


500 


C.  E.  FERREE  AND  G.  RAND 


ference  of  the  diaphragm  is  fastened  a  pointer  which,  as  the  diaphragm 
is  opened  and  closed,  moves  over  a  translucent  millimeter  scale.  This 
scale  is  mounted  over  a  slot  in  the  projection  tube  and  receives  its 
illumination  from  the  light  inside  of  the  tube.  The  inside  of  the  tube 
is  painted  a  mat  black.  At  the  further  end  of  the  projection  tube, 
18.1  em.  from  the  illuminated  aperture,  in  a  brass  ring  and  collar  is 
mounted  the  focusing  lens.  This  lens  is  7.5  cm.  in  diameter  and  has 
a  focal  length  of  14.8  cm.  On  the  platform  supporting  the  lamp  house 


Fig.  14 

are  mounted  a  small  Weston  ammeter  and  a  small  rheostat  to  guard 
against  fluctuations  in  the  current  and  consequent  fluctuations  in 
light  intensities.  In  order  that  any  line  of  the  chart  may  be  illumi- 
nated at  will,  the  lamp  house  is  mounted  on  the  end  of  a  rod  which  is 
raised  and  lowered  by  means  of  a  rack  and  pinion.  The  test  card  is 
mounted  at  a  distance  of  81  cm.  from  the  focusing  lens.  A  photo- 
graph of  the  apparatus  is  shown  in  Fig.  14. 

In  order  that  the  intensity  of  light  used  at  any  time  may  be  known, 
a  calibration  chart  is  provided  in  which  are  given  the  readings  on  the 
millimeter  scale  and  the  equivalent  meter-candle  values  at  the  test 


Contributions  to  the  Science  and  Practice  of  Ophthalmology      501 

card.  This  calibration  was  accomplished  as  follows :  The  lamp  house 
was  removed  and  mounted  on  a  photometer  bar  at  a  distance  from  the 
photometer  head  equal  to  its  original  distance  from  the  test  card. 
The  scale  was  then  gone  over  point  by  point  and  the  meter-candle 
value  of  the  light  at  the  photometer  head  was  measured.  These  values 
were  corrected  to  conform-  at  the  center  of  the  card  to  the  cosine  law.1 

For  our  own  use  in  the  laboratory  we  have  preferred  to  substitute 
for  the  Snellen  chart  a  single  test  character,  the  broken  circle  (the 
international  test-object),  which  can  be  turned  in  different  directions 
and  the  judgment  of  its  direction  rather  than  the  recognition  of  the 
character  be  required  of  the  observer  as  a  test  of  discrimination.  Our 
reasons  for  this  preference  are  as  follows:  (1)  A  test  letter  may  be 
recognized  when  it  is  not  seen  at  all  clearly.  Recognition  is  too  de- 
pendent on  extraocular  functions  to  be  used  with  precision  as  a  measure 
of  ocular  capacity.  (2)  The  different  letters  of  the  Snellen  chart  set 
an  unequal  task  for  the  resolving  power  of  the  eye.  (3)  An  objective 
check  is  had  on  the  judgment.  This  is  especially  helpful  in  case  of 
children  and  the  unintelligent,  untrained,  or  subjective  type  of  adult. 
(4)  By  the  use  of  the  same  test  character  turned  in  different  directions 
at  will  all  possibility  of  learning  the  test  series  is  eliminated.  Also  the 
test-object  becomes  more  valuable  for  the  detection  of  astigmatisms. 
And  (5)  at  low  illuminations  the  eye  fatigues  very  rapidly.  Thus  if 
the  task  is  the  reading  of  the  whole  line  of  letters  the  results  obtained 
measure  not  only  acuity,  but  the  power  to  sustain  acuity  which  may 
or  may  not  be  compatible  with  the  purpose  of  the  test. 

1.  THE  USE  OF  THE  ILLUMINATION  SCALE  FOR  THE  DETECTION  OF 
SMALL  ERRORS  IN  REFRACTION  AND  IN  THEIR  CORRECTION. — There  are 
doubtless  many  ways  in  which  sensitivity  can  be  added  to  the  acuity 
test  for  the  detection  of  small  errors  in  refraction  and  in  their  correc- 
tion. In  connection  with  the  problems  which  we  have  undertaken 
during  the  past  ten  years  involving  modifications  and  refinements  in 
functional  testing,  three  principles  have  come  to  light  which  can  be 
used  very  effectively  to  this  end :  (1)  An  undue  lag  or  slowness  of  dis- 
crimination and  of  making  the  adjustments  needed  for  clear  seeing. 
(2)  A  marked  loss  in  power  to  sustain  clear  seeing.  And  (3)  an  in- 
crease in  the  amount  of  light  required  just  to  discriminate  details  in 
the  standard  acuity  object.  The  devising  of  test  methods  based  on 

1  For  the  calibration  chart  and  the  calibration  curve  in  which  the  divisions  of 
the  millimeter  scale  are  plotted  against  meter-candle  values  at  the  test  card,  see 
Amer.  Jour.  Ophthal.,  May,  1920,  iii. 


502  C.  E.  FERREE  AND  G.  RAND 

the  first  two  of  these  principles  has  been  treated  of  in  former  papers. 
The  third  alone  will  be  considered  here. 

The  relation  of  the  illumination  scale  to  the  detection  of  small  errors 
in  refraction  and  in  their  correction  may  be  stated  briefly  as  follows : 
Insofar  as  the  test-object  is  concerned,  clearness  of  seeing  depends 
both  upon  the  value  of  the  visual  angle  subtended  and  the  intensity  of 
the  illumination.  It  follows  from  this  that  either  the  illumination 
scale  or  the  visual  angle  scale  may  be  used  for  the  detection  of  errors 
in  refraction,  i.  e.,  in  the  diagnostic  procedure  either  the  illumination 
may  be  held  constant  and  the  visual  angle  varied,  or  the  converse. 
Since  the  visual  angle  scale  sustains  by  convention  a  1  :  1  relation  to 
acuity  while  acuity  changes  slowly  with  change  of  illumination  for  all 
but  very  low  illuminations,  the  illumination  scale  possesses  the  greater 
sensitivity  for  the  detection  of  small  errors  in  refraction — also  the 
greater  feasibility  of  contrivance  and  manipulation.  Used  in  this  way 
the  illumination  scale  becomes  in  effect  an  amplifying  scale — some- 
what analogous  to  the  use  of  the  tangent  scale  in  detecting  small 
deflections  in  the  magnet  system  of  a  galvanometer — and  has  an  ad- 
vantage in  sensitivity  in  proportion  to  the  amplification.  In  clinic 
practice  it  has  been  shown  to  be  of  particular  value  in  determining  the 
exact  amount  and  placement  of  the  correction  of  astigmatisms.  That 
is,  if  the  eye  has  equal  resolving  power  in  all  meridians,  the  amount  of 
light  required  just  to  discriminate  the  test-object  in  all  meridians  will 
be  the  same ;  if  the  resolving  power  is  not  equal,  the  amount  of  light 
required  will  be  different  in  the  different  meridians  and  different  in 
proportion  to  the  amplification  represented  by  the  illumination  scale. 
This  gain  in  sensitivity  over  the  clinic  methods  is  needed  in  particular 
to  determine  the  exact  amount  of  the  correction  in  case  of  high  astig- 
matisms and  both  the  amount  and  exact  placement  of  the  correction 
in  case  of  low  astigmatisms.  The  checking  up  of  a  number  of  cases 
shows  that  the  corrections  by  the  clinic  methods  may  be  and  fre- 
quently are  off  from  0.12  to  0.25  diopter  in  the  strength  of  the  cylinder 
and,  in  case  of  low  astigmatisms,  from  5  to  20  degrees  in  the  placement 
of  the  cylinder  axis.  While  errors  of  this  magnitude  may  or  may  not 
be  troublesome  in  the  ordinary  uses  of  the  eye — sometimes  they  are 
very  troublesome  indeed  and  perhaps  always  tend  in  time  to  increase 
the  amount  of  the  defect — they  do  constitute  a  much  more  serious 
handicap,  in  fact  an  actual  disqualification,  for  work  or  vocations  re- 
quiring special  ocular  proficiencies,  e.g.,  keen  acuity, particularly  keen 
acuity  at  low  illuminations;  speed  in  the  use  of  the  eye,  especially 


Contributions  to  the  Science  and  Practice  of  Ophthalmology      503 

speed  of  discrimination  and  of  making  the  adjustments  needed  for 
clear  seeing;  etc.  Moreover  a  considerably  greater  amount  of  light 
is  required  as  a  comfortable  and  efficient  working  minimum  by  the 
poorly  than  by  the  well  corrected  eye.  Indeed  our  experience  with  the 
tricornered  relation  of  intensity  of  light,  resolving  power,  and  the 
retinal  sensitivity  to  acuity  has  impressed  us  with  the  relative  impor- 
tance of  resolving  power  in  explaining  the  difference  in  the  amount  of 
light  that  is  required  by  different  people  as  a  working  minimum. 

The  relation  of  the  intensity  of  illumination  to  acuity  may  be  ill§s- 
trated  by  the  curve  shown  in  Fig.  15.  This  curve  represents  the 
average  results  for  four  observers,  tested  by  Koenig.1  In  this  curve 
acuity  is  plotted  along  the  ordinate  and  intensity  of  illumination  along 
the  abscissa.  It  will  be  noted,  for  example,  that  a  change  of  from  1  to 


t\ttcr-  cattcl/es 

Fig.  15. — Showing  the  effect  of  increase  in  intensity  of  light  on  acuity  (four 
observers),  acuity  plotted  against  meter-candles  of  light  normal  to  the  surface  of 
test-object. 

9  meter-candles,  an  increase  of  800  per  cent,  in  the  intensity  of  illumi- 
nation, produced  an  increase  of  only  74  per  cent,  in  acuity;  and  a 
change  from  9  to  100  meter-candles,  an  increase  of  1011  per  cent,  in 
illumination,  produced  an  increase  of  only  28  per  cent,  in  acuity.  The 
amplification  within  the  latter  range  of  illumination  is  doubtless  too 
great  for  feasibility  of  application.  That  is,  too  wide  a  range  of 
illumination  would  have  to  be  used  to  compensate  for  the  difference 
between  the  resolving  power  in  the  poorest  and  best  meridians  in  the 
ordinary  run  of  astigmatisms.  The  range  from  1  to  9  meter-candles  is, 
however,  quite  feasible  and  the  relation  between  the  two  scales  gives 
abundant  sensitivity.  These  values  fall  within  the  range  given  by  the 
apparatus  described  in  the  preceding  chapter,  0.07  to  9.5  meter- 
candles.  The  testing  of  a  large  number  of  astigmatisms  with  this 

1  Ueber  die  Beziehung  zwischen  der  Sehscharfe  und  der  Beleuchtungsintensitat. 
Verhandl.  der  Physikal.  Ges.  in  Berlin,  1885,  xvi,  79-83. 


501  C.  E.  FERREE  AND  G.  RAND 

apparatus  showed  that  in  the  majority  of  cases  the  minimum  amount 
of  light  required  for  the  discrimination  of  the  opening  in  the  broken 
circle  (visual  angle,  1  min.)  in  the  most  favorable  meridian  was  of  the 
order  of  1  to  3  meter-candles ;  in  the  least  favorable  meridian,  of  the 
order  of  6  to  9.5  meter-candles  or  more. 

A  very  convenient  apparatus  for  using  the  illumination  scale  for 
detecting  low  astigmatisms  and  small  errors  in  the  amount  and  place- 
ment of  their  correction  has  been  described  in  the  chapter  immediately 
pfcceding.  For  this  purpose  the  lantern  was  used  to  give  the  varia- 
tions in  illumination  needed  and  the  broken  circle  served  as  the  test- 
object.  The  broken  circle  was  fastened  at  the  center  of  a  graduated 
dial  the  opening  of  which  (visual  angle,  1  min.)  could  be  turned  into 
any  meridian  that  was  desired.  The  angle  of  turning  could  be  read  in 
terms  of  the  divisions  of  the  dial  which  was  graduated  to  correspond 
to  the  readings  on  the  trial  frames  used  in  office  and  clinic  work. 

Doubtless  the  apparatus  can  be  used  for  the  detection  of  astigma- 
tisms in  different  ways  depending  upon  the  experience  and  preference 
of  the  operator.  The  quickest  and  most  feasible  method  is  first  to 
make  an  approximate  determination  of  the  amount  and  placement  of 
the  correction  by  the  clinic  methods  and  employ  the  illumination 
method  only  for  a  more  precise  determination.  In  using  this  method 
as  a  refinement  in  the  clinic  methods,  the  procedure  we  ordinarily 
employ  is  as  follows :  The  patient's  eye  is  fitted  with  a  cylinder  of  the 
strength  and  placement  indicated  by  the  clinic  tests  and  the  minimum 
amount  of  light  required  to  discriminate  the  opening  in  the  circle  is 
determined  in  four  positions,  two  in  the  meridian  of  the  cylinder-axis 
and  two  in  the  meridian  at  right  angles  to  this.  If  the  minima  are  not 
equal  in  these  four  positions,  the  cylinder-axis  is  shifted  and  the 
determinations  are  made  again,  the  four  positions  of  the  opening  of 
the  circle  always  being  in  the  meridian  of  the  cylinder-axis  and  the 
meridian  at  90  degrees  from  it.  If  no  placement  of  the  cylinder  is 
found  which  gives  equal  minima  for  the  four  positions,  the  strength  of 
the  cylinder  is  changed.  The  strength  and  placement  of  cylinder  which 
requires  both  equal  and  the  smallest  amounts  of  light  for  the  four 
positions  of  the  test-object  is  accepted  as  the  final  correction. 

In  the  testing  and  demonstration  of  the  sensitivity  and  service- 
ability of  the  illumination  method  for  determining  the  exact  amount 
and  placement  of  the  correction  of  an  astigmatism  the  following  types 
of  material  have  been  selected:  (1)  Artificial  astigmatisms  made  with 
'cylinders  of  low  diopter  value.  In  choosing  to  include  artificial  astig- 


Contributions  to  the  Science  and  Practice  of  Ophthalmology      505 

matisms  in  this  work  it  should  be  understood  that  we  did  not  consider 
the  artificial  astigmatism  the  precise  functional  equivalent  of  the 
natural  astigmatism.  We  are  too  strongly  impressed  with  the  possi- 
bility that  the  astigmatic  eye  may  progressively  acquire  power  to 
compensate  in  part  for  its  defect  to  be  of  this  opinion.  They  were 
selected  because  we  wished  to  have  in  one  set  of  cases  an  exact 
knowledge  of  the  amount  and  location  of  the  defect  as  a  check  on  the 
determinations  made  by  the  test.  (2)  Natural  astigmatisms  without 
a  cycloplegic.  (3)  Office  and  clinic  cases  with  a  cycloplegic.  The  dif- 
ference in  result  between  the  most  and  least  favorable  meridians  or 
between  a  true  and  false  correction  have  thus  far  been  of  a  consider- 
ably greater  order  of  magnitude  with  than  without  a  cycloplegic  either 
in  case  of  a  natural  or  an  artificial  astigmatism.  (4)  Office  and  clinic 
cases  in  which  the  apparatus  has  been  used  merely  to  check  up  correc- 
tions already  made  by  the  clinic  methods,  objective  and  subjective. 
Among  these  cases  it  was  comparatively  rare  to  find  one  in  which  the 
minimum  amount  of  light  required  to  discriminate  the  test-object  in 
the  corrected  meridian  was  equal  or  nearly  equal  to  that  required  in 
the  other  meridians.  Indeed  in  some  cases  the  difference  between  the 
most  and  least  favorable  meridian  exceeded  the  range  of  variation 
obtainable  with  the  apparatus  when  provided  with  the  100-watt  lamp. 
And  (5)  irregular  astigmatisms.1 

In  our  own  work  we  have  found  that  the  apparatus  would  be  very 
helpful  if  it  were  used  only  to  check  up  the  corrections  made  by  the 
clinic  methods  and  were  not  employed  further  as  an  aid  in  finding  out 
the  exact  amount  and  placement  of  the  correction.  For  example,  but 
very  few  minutes  are  required  to  determine  with  it  whether  any 
given  correction  equalizes  or  levels  up  the  resolving  power  of  the  eye 
in  the  different  meridians.  The  advantage  of  a  checking  method 
which  is  definite  and  at  the  same  time  feasible  can  readily  be  appre- 
ciated by  any  one  who  has  tried  to  decide  by  the  clinic  methods  in  any 
wide  range  of  cases  just  what  should  be  the  exact  amount  and  place- 
ment of  the  correction  of  an  astigmatism.  The  method  has  its  chief 
value  perhaps  in  those  cases  in  which  it  is  particularly  difficult  to  make 
a  decision  by  the  clinic  methods,  that  is,  in  determining  the  exact 
amount  of  the  correction  in  case  of  high  astigmatisms  and  both  the 

1  For  data  showing  the  sensitivity  of  the  method,  see  Visual  Acuity  at  Low 
Illumination  and  the  Use  of  the  Illumination  Scale  for  the  Detection  of  Small 
Errors  in  Refraction,  Amer.  Jour.  Ophthal.,  June,  1920,  iii;  Sensitivity  of  Illumi- 
nation Scale  for  Determining  Exact  Amount  and  Placement  of  Correction  of 
Astigmatism,  ibid.,  January,  1921,  iv. 


503  C.  E.  FERREE  AND  G.  RAND 

amount  and  placement  of  correction  in  case  of  low  astigmatisms.  The 
simple  character  of  the  judgment,  namely,  the  mere  indication  of  the 
direction  in  which  the  opening  of  the  circle  points  instead  of  the  more 
difficult  task  of  deciding  under  the  comparatively  rough  conditions  of 
the  office  and  clinic  test  whether  this  or  that  placement  or  strength  of 
cylinder  gives  the  clearer  vision,  together  with  the  objective  check  on 
the  correctness  of  each  judgment,  also  contribute  to  make  the  method 
especially  valuable  in  case  of  children,  and  the  subjective,  unintelli- 
gent or  untrained  type  of  adult.  A  further  advantage  of  the  method 
as  worked  out  in  connection  with  the  present  apparatus  is  its  great 
sensitivity  for  the  detection  of  irregular  astigmatisms.  The  lack  of 
satisfactory  tests  for  this  troublesome  defect  is  generally  conceded. 

2.  AN  ATTACHMENT  FOR  TESTING  THE  LIGHT  AND  COLOR  SENSE. — 
A  consideration  of  the  foundation  principles  of  the  acuity  apparatus 
reveals  at  a  glance  that  they  lend  themselves  readily  to  light  and 
color  sense  testing  for  clinic  purposes.  In  order  to  convert  the  appara- 
tus in  the  form  described  in  this  paper  into  a  light  sense  tester  three 
features  are  needed:  (a)  the  choice  of  an  aperture  such  that  when 
magnified  fivefold  a  stimulus  is  obtained  of  a  size  and  shape  suitable 
for  a  sensitive  judgment  of  the  threshold  of  sensation;  (b)  the  pro- 
vision of  a  suitable  surface  on  which  to  project  the  magnified  image 
of  the  aperture;  and  (c)  means  of  reducing  the  intensity  of  light  from 
the  acuity  threshold  to  the  light  sense  threshold,  i.  e.,  from  the  amount 
needed  just  to  discriminate  the  standard  acuity  object  to  the  amount 
needed  just  to  arouse  the  light  sensation.  The  iris  diaphragm  used  in 
the  present  form  of  apparatus,  range  of  pupil  5  to  65  mm.,  does  not 
provide  for  this  range  of  intensity  without  changing  the  source  of 
light.  It  is  obvious  that  an  attachment  for  the  further  reduction  of 
the  light  which  does  not  interfere  in  any  way  with  the  use  of  the 
apparatus  for  the  acuity  work,  would  afford  a  more  convenient  means 
of  securing  the  lower  intensities  than  the  changing  of  the  source  of 
light.  Provision  has  been  made  for  this  in  two  ways:  (a)  by  neutral 
absorption  screens  or  filters;  (b)  by  a  Nicol  prism  (polarizer  and 
analyzer) ;  and  (c)  by  a  metal  plate  which  may  be  made  to  move  by 
minute  amounts  across  the  aperture  of  the  iris  diaphragm  by  a  screw 
adjustment.  The  advantage  of  the  two  latter  devices  over  the  perish- 
able filter  is  their  very  greatly  superior  constancy  and  permanency. 
The  advantage  of  the  moving  plate  over  the  Nicol  prism  is  its  extreme 
simplicity.  The  optical  principle  on  which  the  use  of  the  moving  plate 
is  based  is  that  the  image  receives  light  equally  from  all  parts  of  the 


Contributions  to  the  Science  and  Practice  of  Ophthalmology      507 

lens,  therefore  the  transmission  of  light  through  any  segment  of  the 
lens,  whatever  the  size  or  shape  of  that  segment,  gives  an  equal  distri- 
bution of  light  in  the  image.  The  attachment  is  made  so  that  it  will 
hold  any  of  these  reducing  agencies,  leaving  the  operator  an  option  as 
to  which  shall  -be  used.  It  is  fastened  to  a  narrow  collar  which  slips 
over  the  end  of  the  projection  tube  of  the  lantern  and  is  held  in  place 
by  a  set-screw. 

The  testing  of  the  color  sense  is  provided  for  by  inserting  color 
filters  in  the  beam  of  light.  These  filters  are  inserted  in  the  attach- 
ment just  described  immediately  in  front  of  the  lens  and  the  intensity 
of  light  is  cut  down  to  threshold  value  by  means  of  the  iris  diaphragm. 

Color  sense  apparatus  for  clinic  purposes  seems  at  present,  so  far  as 
the  central  field  is  concerned,  to  be  limited  to  the  testing  of  such  gross 
deficiencies  as  are  classed  as  color  blindness.  They  are  of  little  use  for 
detecting  the  smaller  changes  which  mark  the  advance  and  recession  of 
many  pathologic  conditions.  The  present  apparatus  is  designed  for 
detecting  and  measuring  the  degree  of  deficiency  in  terms  of  the 
amount  of  light  of  a  given  range  of  wave-lengths  which  is  required  just 
to  arouse  the  color  sensation.  It  can  be  used,  however,  for  testing 
color  blindness  in  the  conventional  way  by  throwing  the  full  strength 
of  color  on  the  test  surface,  or  if  a  still  higher  intensity  of  light  is 
wanted,  by  turning  the  lantern  around  to  face  the  observer,  instead  of 
the  test  surface,  and  using  the  full  strength  of  the  beam.  If  desired,  a 
ground  glass  plate  can  be  inserted  in  the  filter  holder  to  diffuse  the 
light  and  eliminate  glare,  or  any  strength  of  neutral  filter  to  cut  down 
the  intensity.  Also  by  means  of  the  iris  diaphragm  the  area  of  the 
colored  surface  may  be  varied  from  5  to  65  mm. 

3.  AN  ATTACHMENT  FOR  VARYING  INDEPENDENTLY  THE  SATURA- 
TION AND  BRIGHTNESS  OF  A  COLOR  AND  FOR  COLOR  MIXING. — The 
attachment  just  described  can  be  made  into  the  form  of  a  simple  filter 
holder,  or  it  can  be  made  to  serve  the  purposes  noted  above.  We  have 
constructed  both  types  of  attachment.  The  simple  filter  holder  is 
made  from  three  grooved  metal  strips  8  cm.  long  and  of  appropriate 
width  and  thickness,  built  into  a  three-sided  rectangular  figure  open 
at  the  top.  It  is  fastened  to  a  narrow  collar  which  slips  over  the  end  of 
the  projection  tube  of  the  acuity  lantern  and  is  held  in  place  by  a  set- 
screw.  The  more  elaborate  holder  which  can  be  made  readily  to  serve 
the  purposes  of  both  attachments  is  constructed  as  follows :  A  frame 
holding  one  filter  is  made  to  travel  from  below  in  a  groove  across  the 
aperture  in  the  iris  diaphragm  by  means  of  a  screw  motion.  A  second 


508  C.  E.  FERREE  AND  G.  RAND 

frame  holding  a  filter  or  opaque  plate  as  may  be  desired,  also  operated 
by  a  screw,  is  made  to  travel  from  above  in  the  same  groove  across  the 
aperture  in  the  iris  diaphragm  in  the  opposite  direction.  Each  screw 
is  furnished  with  a  large  head  with  a  finely  graduated  beveled  edge. 
As  the  screw  is  turned  this  head  travels  along  a  vertical  mm.  scale. 
Thus  the  position  and  movement  of  the  filter  can  at  any  time  be 
determined  with  great  exactness  and  the  scale  be  subjected  to  calibra- 
tion in  terms  of  amounts  of  colored  and  colorless  light.  The  optical 
principle  upon  which  this  attachment  is  based  is  that  the  image  re- 
ceives equally  light  from  every  part  of  the  lens.  That  is,  when  the 
colored  filter  covers  a  given  segment  of  the  lens  aperture,  the  light 
transmitted  is  distributed  uniformly  through  the  image  formed  by  the 
lens ;  or  when  an  opaque  plate  covers  a  segment  of  the  lens  the  light 
from  the  remaining  segment  is  distributed  equally  in  the  image.  Thus 
with  the  possibility  of  using  one  colored  filter  alone,  one  colored  filter 
and  an  opaque  plate  to  vary  the  amount  of  white  or  unfiltered  light 
which  mixes  with  the  colored  light,  or  two  color  filters,  quite  a  wide 
range  of  variation  can  be  produced  in  the  composition  and  intensity  of 
the  light  of  which  the  image  is  formed.  For  example,  (a)  by  use  of  one 
filter  the  color  may  be  mixed  with  any  amount  of  the  available  white 
light,  i.  e.,  all  the  tints  of  the  color  may  be  produced  from  full  satura- 
tion to  white;  (b)  by  the  use  of  one  filter  and  the  opaque  plate  all 
degrees  of  saturation  of  the  color  at  a  constant  brightness  may  be 
produced  over  a  wide  range  of  brightnesses  and  all  the  shades  of  the 
color  from  full  saturation  to  black;  and  (c)  by  the  use  of  two  filters 
mixed  colors  can  be  produced  with  any  proportion  of  the  two  com- 
ponents and  of  any  brightness  from  full  saturation  to  white. 

IV.  THE  EFFECT  OF  VARYING  THE  INTENSITY  AND  COMPOSITION  OF 
LIGHT  ON  ACUITY,  SPEED  OF  DISCRIMINATION,  SPEED  OF  ACCOM- 
MODATION, AND  OTHER  IMPORTANT  OCULAR  FUNCTIONS 
Space  will  be  taken  at  this  point  only  for  an  abstract  of  two  articles 
bearing  on  the  above  topics.1     One  of  our  reasons  for  conducting 
studies  of  this  type  and  for  bringing  them  to  the  attention  of  the 
ophthalmologists  is  that  we  may  enlarge  our  knowledge  of  the  princi- 
ples and  possibilities  of  functional  testing  in  relation  to  diagnosis  and 

1  The  Effect  of  Variations  in  Intensity  of  Illumination  on  Functions  of  Impor- 
tance to  the  Working  Eye,  Trans,  of  the  Illuminating  Engineering  Society,  1920, 
xv,  769^801;  The  Effect  of  Variation  of  Visual  Angle,  and  Intensity  and 
Composition  of  Light  on  Important  Ocular  Functions,  Trans.  Illuminating 
Engineering  Soc.,  Feb.,  1922,  xvii. 


Contributions  to  the  Science  and  Practice  of  Ophthalmology      509 

other  important  applications,  and  broaden  our  understanding  of 
clear  seeing  and  the  factors  upon  which  it  depends. 

In  these  articles  the  effect  of  increase  of  intensity  of  light  is  shown 
on  the  following  functions :  acuity,  power  to  sustain  acuity,  speed  of 
discrimination,  and  speed  of  adjustment  of  the  eye  for  clear  seeing  at 
different  distances.  Wide  ranges  in  change  of  illumination  were 
used.  The  effect  was  found  to  be  very  much  greater  on  the  latter 
three  than  on  the  first  of  these  functions.  It  was  measured  both  on 
normal  eyes  and  eyes  with  slight  errors  in  refraction  of  a  type  and 
amount  of  frequent  occurrence  even  in  the  corrected  eye.  The 
benefit  of  the  increase  was  found  to  be  considerably  greater  in  case  of 
these  slight  defects  than  for  the  normal  eye.  A  comparison  was 
made  of  the  effect  of  increase  of  intensity  of  illumination  and  increase 
of  size  of  visual  angle.  The  importance  of  testing  the  neglected 
aspects  of  acuity:  speed  and  power  to  sustain,  in  relation  to  diagnosis, 
vocational  selection  and  hygiene  or  welfare  work  on  the  eye  was 
demonstrated,  and  a  comparison  was  made  of  their  sensitivity  and 
that  of  acuity  and  speed  of  adjustment,  as  test  features  for  picking 
up  small  differences  in  the  functional  powers  of  the  eye. 

The  investigation  was  also  extended  to  include  the  effect  of  varia- 
tions in  the  composition  of  light  on  acuity,  power  to  sustain  acuity 
and  speed  of  discrimination.  Two  intensities  of  light  at  seven  points 
in  the  spectrum  were  used,  all  made  photometrically  equal  at  each 
intensity.  The  highest  acuity,  speed  of  discrimination  and  power  to 
sustain  acuity  were  found  in  the  mid-region  of  the  spectrum  (maxi- 
mum in  the  yellow)  even  though,  as  is  well  known,  lenses  have  their 
highest  resolving  power  for  the  short  wave-lengths.  Again  speed  of 
discrimination  and  power  to  sustain  acuity  were  much  more  affected 
by  the  change  in  the  illumination  condition  (change  of  wave-length) 
than  acuity.  The  relative  importance  of  resolving  power  of  the  re- 
fracting media  and  resolving  power  of  the  retina  is  discussed  in  rela- 
tion to  the  effect  of  changes  in  composition  of  light  on  acuity,  speed 
of  discrimination  and  power  to  sustain  acuity. 

Two  comments  are  added:  (1)  All  of  the  functions  referred  to 
above  are  aspects  of  acuity.  They  are  aspects,  however,  which  are 
not  brought  out  by  the  conventional  method  of  testing  acuity.  The 
conventional  test  of  acuity  takes  little  account  of  either  speed  or 
power  to  sustain,  two  aspects  which  are  not  only  of  great  importance 
to  the  working  efficiency  of  the  eye,  but  are  extremely  sensitive 
indicators  of  differences  in  functional  power,  whether'  due  to  fatigue, 


510  C.  E.  FERREE  AND  G.  RAND 

bad  conditions  of  seeing,  or  refractive  and  pathologic  disturbances. 
Add  either  of  these  aspects  to  the  method  of  testing  acuity  and  the 
effect  is  very  similar,  so  far  as  sensitivity  is  concerned,  to  that  ob- 
tained when  an  amplifier  is  added  to  a  physical  recording  instrument. 
For  example,  changes  of  intensity  of  light  which  produce  compara- 
tively small  differences  in  acuity,  as  ordinarily  tested,  cause  very 
large  changes  in  the  speed  of  discrimination  and  the  power  to  sustain 
acuity.  The  conventional  acuity  test  is,  comparatively  speaking, 
not  only  insensitive,  but  it  is  not  sufficiently  comprehensive  in  the 
range  of  aspects  covered  to  bring  out  differentially  some  of  the  most 
important  functional  powers  of  the  eye. 

(2)  Considered  with  reference  to  the  eye  there  are  three  factors  in 
acuity  or  the  power  of  the  eye  to  see  clearly — the  resolving  power  of 
the  refracting  media,  the  space  discrimination  of  the  retina,  and  its 
sensitivity  to  light.  To  put  it  another  way,  there  are  the  resolving 
power  of  the  refracting  media,  or  the  power  to  form  clear  images  on 
the  retina;  and  the  resolving  power  of  the  retina,  or  the  power  to 
discriminate  detail  in  the  physical  image  formed.  Considered  with 
reference  to  the  stimulus  light,  six  factors  may  be  mentioned  which 
are  effective  in  acuity — the  physical  factors:  intensity,  wave-length, 
and  purity  of  light;  and  their  three  subjective  aspects:  hue,  satura- 
tion and  brightness.  Of  these  the  wave-length  and  purity  alone 
affect  the  resolving  power  of  the  refracting  media  or  the  power  to 
form  clear  images.  Intensity,  hue,  saturation  and  brightness  affect 
the  power  to  discriminate  detail  in  these  images,  or  what  we  have 
called  the  resolving  power  of  the  retina.  For  example,  the  benefit 
of  the  increase  of  intensity  of  illumination,  cited  above,  came  through 
the  effect  on  the  resolving  power  of  the  retina,  not  of  the  refracting 
media.  Again  the  wave-lengths  in  the  middle  of  the  spectrum  gave 
the  highest  acuity,  speed  of  discrimination  and  power  to  sustain 
acuity  although  the  resolving  power  of  the  refracting  media  is  greater 
for  the  shorter  wave-lengths.  Here  the  effect. of  the  more  favorable 
hue  and  saturation  of  these  colors  (yellow,  etc.)  on  the  retina's  power 
of  discrimination  more  than  compensated  "for  the  effect  of  wave- 
length on  the  resolving  power  of  the  refracting  media.  A  third  point 
is,  the  acuity  and  speed  of  the  eye  is  greater  for  green  light  than  for 
red;  but  the  converse  is  true  for  the  power  to  sustain.  Doubtless 
the  explanation  here  is  that  the  refracting  system  has  a  higher  re- 
solving power  for  green  than  for  red;  but  the  retina  sustains  its  re- 
solving power  better  for  the  red  than  for  the  green,  probably  due  in 


Contributions  to  the  Science  and  Practice  of  Ophthalmology      511 

part  to  the  greater  activity  of  the  "streaming  phenomenon"  under 
the  shorter  wave-lengths,  which  is  readily  observed  in  the  experi- 
ments on  the  power  to  sustain.  A  final  striking  example  of  the 
interplay  of  these  two  types  of  resolving  power  is  the  difference  in 
the  effect  of  wave-length  on  acuity  in  the  microscopic  field  and  in 
the  visual  field.  In  the  microscopic  field  the  shorter  wave-lengths 
bring  out  detail  more  clearly,  while  in  the  visual  field  the  longer 
yellow  waves  give  the  higher  acuity.  In  the  latter  case  the  eye  views 
its  image  directly;  in  the  former,  an  image  of  the  object  formed  by  an 
accessory  refracting  system.  That  is,  in  the  former  case  the  relative 
importance  of  the  refractive  resolving  power  is  greatly  exaggerated. 
A  discrepancy  should  be  expected,  therefore,  between  the  effect  of 
wave-length  of  light  on  acuity  as  represented  in  the  natural  eye  and 
in  the  eye  whose  refracting  powers  are  amplified  by  means  of  a  micro- 
scope. In  one  case  the  resolving  power  of  the  retina  is  dominant; 
in  the  other  the  resolving  power  of  the  refracting  system. 

Both  in  administering  to  the  welfare  and  comfort  of  the  eye  and  in 
testing  its  powers  analytically  for  diagnosis  and  other  purposes,  it 
seems  important  to  know  what  factors  influence  the  resolving  power 
of  the  refracting  media;  what  the  resolving  power  of  the  retina;  and, 
roughly  speaking,  in  what  proportions  they  combine  to  influence  the 
total  result  in  clear  seeing. 

V.  THE  ILLUMINATION  OF  TEST  CHARTS 

The  question  frequently  comes  before  standardizing  committees: 
At  what  intensity  of  illumination  should  acuity  be  tested?  Our 
answer  would  be,  It  depends  for  what  purpose  the  test  is  to  be  made. 
There  are  three  obvious  applications  of  acuity  testing:  vocational 
selection,  diagnosis,  and  hygiene  or  welfare  of  the  eye. 

In  the  rating  of  eyes  as  to  fitness  for  vocations,  the  test  should  be 
made  as  nearly  as  possible  at  the  illumination  usually  employed  in 
the  vocation  in  question.  The  study  of  even  a  small  number  of  cases 
shows  that  the  eye  can  not  be  given  the  same  relative  rating  as  to 
acuity  at  different  intensities  of  illumination.  For  example,  ex- 
perience has  shown  in  the  navy  that  only  25  to  30  per  cent,  of  the  men 
accepted  for  the  service  on  the  basis  of  the  conventional  acuity  test 
at  the  higher  illuminations  are  able  to  qualify  for  the  lookout  work 
at  night  on  the  bridge  of  the  battleships.  Further  in  a  test  of  61  ob- 
servers made  by  us,  all  under  28  years  of  age  and  rating  6/4  acuity 
by  the  conventional  test  with  5  foot-candles  of  light  on  the  test  chart, 
13  per  cent,  rated  below  6/6  at  0.55  foot-candle  of  light  and  33  per 


512 


C.  E.  FERREE  AND  G.  RAND 


cent,  below  6/6  at  02  foot-candle.  The  acuity  of  the  remainder  was 
6/6  or  better  at  these  illuminations.  If  speed  in  the  use  of  the  eye 
at  low  illuminations  be  added  to  the  requirement,  the  scatter  is  very 
much  greater  still.  The  amount  of  time  required  just  to  discriminate 


3      4      f      &       7    .   $      <?   ;  10     n      i 


Fig.  16. — Showing  the  effect  of  increase  of  intensity  of  light  on  acuity  for 
eye  with  normal  refraction,  and  same  eye  made  slightly  astigmatic:  A,  Acuity 
plotted  against  foot-candles;  B,  percentage  gain  in  acuity  plotted  against  foot- 
candles. 

1  minute  of  visual  angle  in  this  group  of  observers  who  were  all  put 
in  the  same  class  by  the  acuity  test  at  the  high  illumination,  covered 
a  range  from  slowest  to  fastest  of  1333  per  cent,  at  0.55  foot-candle 
and  of  1443  per  cent,  at  0.2  foot-candle.  It  is  quite  obvious  that  any 


Contributions  to  the  Science  and  Practice  of  Ophthalmology      513 

attempt  to  rate  eyes  for  vocational  purposes  at  only  one  order  of  in- 
tensity of  illumination  is  based  on  a  lack  of  knowledge  of  the  differ- 
ential effect  for  different  eyes  of  intensity  of  illumination  on  the 
power  of  the  eye  to  see  clearly. 

All  will  agree,  we  suppose,  that  the  object  in  diagnosis  is  to  give 
the  test  under  the  conditions  providing  the  maximum  sensitivity  for 
detecting  errors  in  refraction.  A  glance  at  the  curves  given  in  Fig. 
16  is  sufficient  to  show  that  this  maximum  degree  of  sensitivity  is  not 
obtained  at  the  higher  illuminations.  For  the  small  uncorrected 
astigmatic  errors  represented  in  the  chart  the  difference  in  acuity 
is  scarcely  detectable  at  the  higher  illuminations,  but  readily  detectable 
at  the  lower.  The  reason  for  this  is  not  hard  to  understand.  The  details 
in  the  slightly  blurred  astigmatic  image  can  be  discriminated  at  high 
illumination  but  not  at  low  because  of  the  effect  of  increase  of  inten- 
sity of  illumination  on  the  resolving  power  of  the  retina.  This  increase 
in  diagnostic  sensitivity  was  further  directly  tested  out  as  follows: 
Low  artificial  astigmatisms  were  made  and  corrected.  Starting  with 
the  proper  placement  of  the  correcting  cylinder,  the  axis  was  shifted 
from  its  position  by  graded  changes,  ascending  and  descending  series, 
until  the  judgment  of  just  noticeable  difference  in  the  clearness  of 
seeing  of  the  letter  B  subtending  a  visual  angle  of  5  min.  was  made. 
This  was  done  at  15,  10,  5,  3,  0.46  and  0.25  foot-candles  of  light  on  the 
test  card.  The  tests  were  made  very  carefully.  Seven  concordant 
judgments  out  of  10  were  accepted  as  the  criterion  of  just  noticeably 
different  in  any  one  set  of  trials.  The  results  are  shown  in  Table  1. 

TABLE  1 


Observer 

Astigmatism 

Degrees  cylinder  must  be  placed  off 
axis  to  give  just  noticeable  dif- 
ference of  clearness 

High  Illumination 
(Average  of  results 
at  5  and  10  f.c.) 

Low  Illumination 
(Average  of  results 
at  0.25  and  0.46  f.c.) 

H.  . 

0.25  cyl.  ax.  90° 
0.25  cyl.  ax.  90° 
0.25  cyl.  ax.  180° 
0.37  cyl.  ax.  180° 
0.50  cyl.  ax.  90° 
0.75  cyl.  ax.  90° 

15.0 
13.5 
8.5 
13.5 
20.3 
9.0 

2.5 
5.0 
6.5 
4.0 
9.5 
5.0 

B   

L   

s        

c       

Bs           

33 


514  C.  E.  FERREE  AND  G.  RAND 

In  any  hygiene  or  welfare  test  of  the  favorableness  of  working  con- 
ditions for  the  eye,  the  tests  should  also  be  made  at  more  than  one 
intensity  of  illumination.  Conditions  which  are  apparently  accept- 
able at  the  higher  illuminations  are  often  far  from  equally  acceptable 
at  the  lower  illuminations.  In  all  cases  it  will  be  found  too  that  the 
sensitivity  of  the  acuity  test  whether  the  purpose  be  vocational, 
diagnostic  or  hygienic,  is  very  greatly  enhanced  when  the  procedure 
is  made  to  include  speed,  power  to  sustain  and  accuracy,  instead  of 
accuracy  alone  as  is  the  case  in  the  conventional  method  of  testing 
acuity. 

DISCUSSION 

DR.  ALEXANDER  DUANE  (New  York  City) :  The  paper  of  Drs.  Ferree  and 
Rand  has  many  points  of  clinical  value.  One  outstanding  fact  is  the  great 
variability  of  the  illumination  even  in  what  seems  like  ordinary  daylight  and 
the  corresponding  variations  in  visual  acuity  thereby  induced.  Another  is 
the  effect  of  low  illumination  in  accentuating  the  difficulties  of  vision  produced 
by  small  refractive  errors;  and,  as  a  corollary,  the  enhancement  of  an  ability 
to  detect  these  errors  if  we  examine  by  reduced  illumination.  While  such  a 
reduction  is  effected  most  scientifically  by  the  apparatus  of  the  authors,  it 
can  also,  as  I  have  found,  be  accomplished  in  a  rough-and-ready  way  by 
darkening  the  room  or  placing  a  dark  glass  before  the  eye  tested;  and  these 
simple  expedients  actually  do  help  us  to  come  to  a  more  certain  decision  in 
some  instances  where  we  are  in  doubt  as  to  the  strength  or  axis  of  a  weak 
cylinder.  As  the  authors  point  out,  their  observations  show  why  some 
patients  with  very  slight  refractive  errors  demand  a  good  illumination  and 
suffer  if  they  do  not  get  it. 

Another  point  most  useful  to  the  clinician  is  the  fact  that  visual  acuity  as 
we  measure  it  is  a  complex  process,  involving  not  simply  the  form  sense  but 
also  the  light  sense  and  probably  to  some  extent  the  color  sense  as  well.  Most 
enlightening  is  the  fact  brought  out  by  the  authors  that  in  our  tests  we  should 
be  concerned  not  with  visual  acuity  alone,  but  also  with  the  power  to  sustain 
visual  acuity,  the  speed  of  discrimination  and  the  speed  of  adjustment. 
Failure  in  the  first  regard  must  conduce  to  asthenopia  in  spite  of  apparently 
normal  vision  and  accurate  correction,  and  failure  in  the  others  must  render 
an  eye  unfit  for  certain  of  the  finer  functionings,  e.  g.,  for  work  where  the  object 
of  fixation  is  moving  rapidly  or  for  any  other  reason  is  changing  its  physical 
characteristics. 

The  observations  on  the  great  variation  in  the  color  fields  produced  by 
even  slight  changes  in  illumination  have  also  an  important  clinical  application. 
They  should  induce  us  either  to  attempt  to  standardize  our  color-field  tests 
in  some  absolute  and  yet  practical  way,  or  else  to  cease  ascribing  to  them  any 
but  a  quite  subordinate  importance.  To  the  latter  view  I  have  come  after 
repeated  experiences  of  the  untrustworthiness  of  the  tests  as  ordinarily 
applied. 

Finally,  the  remarks  on  the  use  of  the  acuity  lantern  as  a  color  mixer  and  as 


Contributions  to  the  Science  and  Practice  of  Ophthalmology      515 

a  means  of  testing  the  lesser  deficiencies  of  the  color-sense  indicate  what  may 
possibly  be  a  very  serviceable  application  of  the  instrument. 

DR.  LUTHER  C.  PETER  (Philadelphia):  We  have  watched  with  unusual 
interest  the  evolution  of  this  perimeter.  Conscious  of  the  gross  defects  and 
of  the  inaccuracies  of  studies  made  on  the  extreme  periphery  by  means  of  the 
perimeters  at  our  disposal,  the  writer  has  largely  abandoned  a  study  of  minute 
peripheral  changes,  depending  either  upon  such  qualitative  and  quantitative 
changes  as  one  can  determine  on  tangential  planes  for  the  detection  of  early 
peripheral  loss.  While  this  method  also  falls  far  short  of  the  truth  in  slight 
contractions,  a  study  of  green  and  even  red  with  low  intensity  stimuli  at 
least  established  a  normal  for  an  individual  patient  with  which  subsequent 
examination  could  be  compared,  all  at  a  minimum  loss  of  time  and  with  less 
trouble  than  when  taken  on  ordinary  perimeters. 

To  be  able,  however,  to  examine  a  peripheral  field  with  a  technique  which 
in  accuracy  does  not  fall  far  below  that  of  the  physiologic  laboratory,  and  to 
make  such  studies  reproducible,  has  been  the  hope  of  the  author.  This  hope 
promises  well  to  be  realized  in  the  perimeter  which  Drs.  Ferree  and  Rand 
have  devised.  Whatever  criticisms  may  be  offered,  therefore,  will  be  con- 
structive or  corrective  from  the  clinical  standpoint  and  not  to  detract  from 
what  we  are  all  trying  to  obtain,  namely,  accuracy. 

In  the  application  of  the  instrument,  the  designers,  in  order  to  call  atten- 
tion to  the  varying  results  which  may  be  obtained  simply  by  varying  degrees 
of  illumination,  the  intensity  of  the  stimuli,  by  pre-exposure  and  surrounding 
field,  have  clearly  upset  our  beliefs  as  to  the  relative  breadth  of  the  several 
color  fields.  They  have  established  authoritatively  the  fact  that  if  the  inten- 
sity of  the  stimuli  is  properly  increased,  the  peripheral  retina  is  sensitive  to 
blue  and  red  up  to  the  limits  of  the  form  field,  whereas  green  falls  far  short. 
Charts  3  to  6  graphically  illustrate  this  well-established  fact.  It  is  important 
to  observe,  however,  that  the  several  colors  require  increasing  degrees  of 
intensity  in  order  to  make  this  condition  possible.  When  we  turn  to  clinical 
perimetry,  conditions  are  different.  Illumination,  pre-exposure  and  surround- 
ing field  are  the  same  as  in  establishing  color  thresholds,  intensity  of  each  color 
stimulus,  however,  remaining  relatively  the  same  from  center  to  periphery. 
Red  and  blue  fields  under  these  conditions  may  interlace,  they  may  be  con- 
centric, the  blue  lying  without  the  red,  or  vice  versa,  the  difference  depending 
upon  the  absolute  intensities  of  the  stimuli. 

The  question  naturally  arises,  cannot  a  uniform  normal  be  established  by 
varying  the  pigments  so  that  interlacing  in  the  normal  individual  can  be 
eliminated?  A  study  of  the  chromatic  thresholds  in  Figs.  3  and  4  would  lead 
one  to  think  that  this  is  possible.  If  this  can  be  done,  it  will  relieve  a  situa- 
tion which  is  most  confusing.  By  our  present  inaccurate  methods  blue  is 
always  found  outside  the  red  limits.  If  by  more  accurate  methods,  as  made 
possible  in  this  new  perimeter,  simply  by  varying  the  intensity  of  the  pigments 
the  same  results  may  be  obtained,  why  cannot  a  standard  in  pigments  be 
fixed  so  as  to  eliminate  interlacing  in  the  normal?  If  studies  in  pathology 
are  to  give  a  true  measure  of  pathological  retinal  sensitivity,  the  normal 


516  C.  E.  FERREE  AND  G.  RAND 

should  be  made  as  definite  as  possible.  Unless  this  can  be  done,  our  dilemma 
in  determining  what  changes  are  due  to  pathological  loss  of  sensitivity  and 
what  changes  are  due  to  faulty  technique  will  only  be  carried  further  into  the 
peripheral  field.  The  same  uncertainty,  although  to  a  more  refined  degree, 
will  embarrass  our  studies. 

By  the  suggested  changes  in  technique  made  possible  in  a  properly  stan- 
dardized perimeter  such  as  the  one  presented,  the  principles  of  which  can  also 
be  applied  to  tangent  planes,  red  and  blue  in  the  normal  are  the  only  con- 
flicting colors.  If  the  writer  has  properly  interpreted  the  paper  under  discus- 
sion, blue  in  the  normal  can  be  made  to  fall  without  or  within  the  red  limits 
by  simply  varying  the  intensity  of  the  pigment  stimuli.  If  this  is  correct,  it 
would  be  most  desirable  to  have  the  blue  to  fall  regularly  outside  the  red 
limits  in  normal  conditions.  This  will  continue  to  make  our  present  limits 
of  green,  red,  blue  a  fixed  normal  and  will  be  a  guide  to  a  beginner  to  check 
up  on  his  work  in  developing  a  satisfactory  technique.  It  will  do  much  more. 
There  seems  to  be  a  definite  relation  between  shrinkage  of  the  blue  limits  and 
nutritional  disturbances  of  the  neuro-epithelium  or  the  receptive  part  of  the 
neuron.  On  the  other  hand,  according  to  our  studies  in  the  past,  red  and 
green  contraction  seems  to  be  greater  than  blue  in  disturbances  of  the  trans- 
mitting part  of  the  neuron  or  of  the  inner  neuron  and  its  axis  cylinders.  It  is 
possible  that  this  grouping  of  pathologic  changes  may  undergo  revision  with 
better  technique.  A  selection  of  the  proper  pigment,  therefore,  will  help  us 
to  confirm  our  present  beliefs,  or  convince  us  that  we  have  been  in  error.  Such 
a  choice  of  the  stimuli  will  also  tend  to  clear  up  the  perplexing  problem  of 
interlacing,  especially  of  red  and  blue. 

Without  having  had  an  opportunity  to  use  this  instrument  in  practical 
clinical  work,  it  is  only  possible  to  speak  in  a  speculative  manner.  In  it  are 
embodied  the  essentials  of  correct  methods  of  measurement  of  the  peripheral 
field  under  standard  conditions.  It  promises  much  for  those  who  are  willing 
to  give  time  to  this  method  of  study.  To  the  group  of  men  who  really  appre- 
ciate the  refinements  of  careful  diagnostic  aids,  it  will  be  a  welcome  addition 
to  office  equipment. 

DR.  WILLIAM  L.  BENEDICT  (Rochester,  Minn.):  Inasmuch  as  this  paper 
was  written  for  those  who  deal  largely  with  diseased  eyes  in  office  and  clinical 
work,  it  seems  that  we  should  judge  of  its  value  by  the  standards  set  for  office 
and  clinical  work  and  not  by  the  things  that  are  found  by  the  refinements  of 
laboratory  investigations.  It  is  well  known  that  we  can  vary  the  size  of  the 
field,  that  we  can  vary  the  acuity,  and  stimulate  the  fatiguability  of  the  retina 
by  changing  the  length  of  adaptation,  the  source  of  illumination,  and  the. 
circumstances  under  which  people  are  being  tested.  If  this  is  possible  with 
such  variability  for  normal  individuals,  how  much  more  must  it  apply  to 
people  who  are  undergoing  tests  under  circumstances  to  which  they  are  not 
accustomed.  Individuals  who  are  being  subjected  to  routine  examination 
for  neurotic  conditions  find  themselves  more  or  less  upset  when  they  come  to 
tests  that  require  the  co-operation  that  most  of  these  tests  of  precision  need. 
Individuals  suffering  from  headache  associated  with  brain  tumor,  those  asso- 


Contributions  to  the  Science  and  Practice  of  Ophthalmology     517 

ciated  with  general  metabolic  disturbance  we  find  in  disease  of  the  endocrine 
organs,  are  very  uncertain  as  to  their  co-operation  and  as  to  the  purpose  for 
which  the  tests  are  being  applied.  So  that  there  must  be  great  uncertainty 
of  results  unless  they  are  carefully  interpreted  by  the  man  who  makes  the 
examination.  It  is  important  that  the  one  who  applies  the  tests  apply  them 
with  a  sense  of  appreciation  of  the  delicacy  of  the  individual  being  tested  as 
well  as  the  delicacy  of  the  instrument. 

I  wish  to  say  particularly  in  this  regard  that  often  patients  worked  with 
under  such  abnormal  conditions  respond  with  very  great  sameness  to  the 
ordinary  rough  tests.  It  is  only  by  repeated  examinations  with  tests  for 
color  fields  with  ordinary  colors,  when  we  get  uniform  fields  day  after  day, 
that  we  are  able  in  a  long  series  of  fields  to  work  out  the  diminution  of  the 
light  sense  and  of  the  field  area  to  a  degree  which  is  sufficient  to  prognosticate 
the  outcome  of  a  rather  serious  neurotic  lesion. 

I  wish  to  emphasize  the  importance  of  taking  the  color  fields,  particularly 
in  the  periphery,  because  some  of  our  neuro-ophthalmic  surgeons  are  beginning 
to  cast  doubt  upon  the  importance  of  taking  peripheral  fields.  It  is  impor- 
tant, it  seems  to  me,  that  this  be  kept  up,  and  that  we  urge  as  much  as  we  can 
that  accuracy  of  the  fields  in  the  periphery  should  be  as  important  as  accuracy 
of  the  fields  in  the  central  portion. 

The  particular  things  we  are  to  receive  from  Dr.  Ferree's  laboratory  work 
is  the  importance  of  getting  the  correct  illumination  at  the  side  as  well  as  in 
front,  and  we  know  we  can  do  this  with  an  ordinary  perimeter  if  we  will  regu- 
late our  illumination.  Then,  with  the  individual  watched  as  to  his  fixation, 
we  can  test  with  sufficient  accuracy  the  visual  fields  so  that  we  can  urge  on 
the  surgeon  the  possibility  of  improvement  by  his  type  of  treatment. 

DR.  WILLIAM  ZENTMAYER  (Philadelphia) :  As  chairman  of  the  committee 
of  which  Prof.  Ferree  was  also  a  member,  appointed  by  the  American  Ophthal- 
mological  Society  to  report  on  the  Standardization  of  Test  Cards  and  Perim- 
eters, I  feel  that  I  should  say  a  few  words  of  appreciation  of  Prof.  Ferree's 
work  in  connection  with  the  illumination  of  the  perimeter.  . 

By  the  plan  adopted  the  perplexing  problem  of  having  the  arc  of  the  perim- 
eter equally  and  sufficiently  illuminated  in  all  meridians  and  at  all  points 
on  the  same  meridian,  has  been  solved.  The  method  by  which  this  has 
been  accomplished  is  as  simple  as  it  is  ingenious,  and  can  be  adapted  to  any 
of  the  perimeters  based  upon  a  revolving  arc.  He  has  added  features  which 
give  to  the  instrument  a  much  greater  scientific  value,  as  office  tests  can  now 
be  made  under  standardized  conditions  corresponding  to  those  employed  in 
the  laboratory.  Control  of  fixation,  one  of  the  most  difficult  factors  in  field 
taking,  is  effected  in  a  practical  way. 

The  campimeter  attachment  is  a  feature  of  worth  and  is  superior  to  the 
hand  campimeter  in  that  it  is  uniformly  illuminated  and  permits  the  examiner 
to  keep  the  eye  being  tested  under  observation. 

MR.  J.  GRAY  CLEGG  (Manchester,  England) :  I  feel  under  obligations  to 
Dr.  Ferree  for  the  excellent  instruments  he  has  devised.  They  will  be  of 


518  C.  E.  FERREE  AND  G.  RAND 

considerable  assistance  to  the  Council  of  British  Ophthalmologists  who  are 
investigating  some  similar  problems.  From  a  practical  point  of  view,  how- 
ever, one  strongly  desires  a  good  perimeter  to  get  reliable  results  for  compari- 
son, because  atmospheric  conditions  vary  and  we  have  to  examine  patients 
both  day  and  night. 

I  do  not  know  whether  Dr.  Ferree  has  adopted  this  method,  but  I  would 
like  to  ask  whether  the  use,  during  these  examinations,  of  an  artificial  day- 
light glass  for  illuminating  the  objects  on  the  scotometer  and  perimeter  is  a 
really  practical  proposition  for  office  work. 

DR.  C.  E.  FERREE  (closing) :  In  reply  to  Dr.  Clegg  I  would  say  that  the 
problem  given  to  us  by  the  Committee  on  the  Illumination  of  Perimeters 
and  Test  Charts  was  to  devise  a  means  of  illuminating  the  perimeter  arm 
with  light  of  a  good  intensity  and  quality  so  that  every  point  on  the  arm  in 
any  meridian  in  which  it  may  be  placed  shall  receive  equal  intensities  of  light. 
Good  quality  means,  of  course,  a  close  approximation  to  daylight.  The 
satisfying  of  this  specification  has  caused  us  considerable  difficulty.  A  glass 
sufficiently  blue  to  absorb  the  excess  of  the  long  wave-lengths  present  in 
artificial  light  lowers  the  total  transmission  so  much  as  to  make  it  difficult 
to  get  the  intensity  of  illumination  needed  in  perimetry  with  a  lamp  of  a 
wattage  feasible  to  use  in  type  of  the  lamp  house  which  has  to  be  employed. 
In  one  of  the  instruments  shown  here  the  light  passes  from  the  lamp  to  the 
perimeter  arm  through  a  daylight  cylinder  or  collar.  The  light  so  filtered 
is  a  close  spectro-photometric  approximation  to  north  sky  light  but  the  total 
transmission  is  only  15  per  cent.  In  the  other  instrument  demonstrated  the 
light  filters  through  a  double  etched  75-watt,  type  C  Mazda  bulb.  This  bulb 
gives  a  higher  transmission  but  only  a  rough  approximation  to  daylight 
composition.  With  this  lamp  17  foot-candles  of  light  are  incident  on  the 
perimeter  arm.  One  objection  to  all  blue  bulb  lamps  is  that  the  intense 
heat  generated  by  the  filament  causes  the  glass  to  lose  its  color  and  to  change 
its  transmission.  We  will  probably  use  finally  a  collar  of  approximately 
the  same  transmission  as  the  type  C  bulb  in  connection  with  a  clear  bulb 
lamp.  This  collar  will  be  far  enough  removed  from  the  filament  not  to  be 
affected  seriously  by  the  heat  which  it  radiates. 

In  reply  to  Dr.  Peter  I  would  say  that  it  would  be  quite  possible  to  get 
pigment  stimuli  so  graded  as  to  reflection  coefficient  that  the  limits  of  the 
blue  field  would  lie  just  outside  the  limits  of  the  red  field  for  the  normal  eye. 
Interlacing,  which  is  the  first  step  toward  reversal,  might  then  have  a  diag- 
nostic value  provided  that  the  intensity  of  light  on  the  perimeter  arm  were 
held  constant.  However,  the  exact  composition  of  such  pigments  would 
have  to  be  determined  empirically,  specified  and  carefully  manufactured 
according  to  specification.  It  does  not  seem  to  me  that  enough  advantage 
would  be  gained  by  the  procedure  to  pay  for  the  trouble  involved.  In  fact, 
I  doubt  whether  any  advantage  would  be  gained.  With  either  the  Hering 
or  the  Heidelburg  pigment  stimuli  and  the  intensity  of  light  used  in  our  perim- 
eter the  limits  for  red  and  blue  are  interlacing  for  the  normal  eye.  An 
amount  of  pathologic  disturbance  which  would  change  the  concentric  fields 


Contributions  to  the  Science  and  Practice  of  Ophthalmology     519 

proposed  by  Dr.  Peter  to  interlacing  fields  would  change  interlacing  fields  to 
concentric  fields  with  red  or  blue  on  the  outside,  depending  on  whether  the 
red  or  blue  sensitivity  was  the  more  affected  by  the  pathologic  condition. 
Both  procedures  have  their  diagnostic  features  plainly  marked  and,  so  far 
as  one  can  anticipate,  there  would  be  no  difference  in  sensitivity  between 
them.  However,  the  clinician  should  be  able  to  speak  to  the  point  of  com- 
parative diagnostic  advantages  better  than  I. 

Dr.  Benedict  speaks  of  the  ability  to  secure  uniform  results  under  ordinary 
daylight  illumination.  In  our  paper  we  show  the  variations  obtained  over  a 
range  of  illumination  made  equal  photometrically  to  that  occurring  from  noon 
to  four-thirty  on  a  bright  winter  day  in  a  well-lighted  room.  If  one  is  to 
secure  results  reproducible  within  acceptable  limits  of  precision  under  the 
vicissitudes  of  daylight  illumination  in  this  latitude,  he  will  have  to  be  very 
watchful  indeed.  It  could  be  done  with  an  illuminometer  in  a  room  properly 
curtained  for  control  of  intensity.  Even  then  reproducible  illumination  is 
all  that  could  be  hoped  for.  A  constant  amount  of  light  at  every  point  on 
the  arm  for  every  position  in  which  the  arm  might  be  placed  would  be  scarcely 
possible  to  obtain.  I  surmise  that  Dr.  Benedict  means  to  urge  us  not  to  be 
too  pessimistic  about  perimetry  even  under  the  unequal  conditions  afforded 
by  daylight  illumination.  Perimetry  done  by  a  careful  physician  even  under 
such  conditions  is  very  much  better  than  no  perimetry  at  all.  I  think  that 
we  would  all  be  very  glad  to  subscribe  to  this  principle.  However,  I  cannot 
urge  too  strongly  the  need  for  a  precise  control  of  the  intensity  of  light  falling 
on  the  perimeter  arm.  It  is  by  far  the  most  important  control  we  have  yet  to 
attain  in  the  general  practice  of  perimetry.  I  say  this  without  any  wish  to 
detract  from  the  importance  of  the  other  variable  factors  the  provisions  for 
the  control  of  which  we  have  discussed  and  demonstrated.  All  are  agreed, 
I  believe,  that  what  we  especially  need  for  diagnosis  is  constancy  of  conditions 
from  day  to  day  and  from  office  to  office,  as  scientifically  correct  and  as 
sensitive  as  may  be,  in  order  that  norms  may  be  established  and  results  widely 
compared  as  to  the  deviations  found  under  the  various  pathologic  conditions. 
When  this  is  done,  there  is  every  reason  to  believe  that  much  of  the  confusion 
that  now  exists  as  to  results  and  their  meaning  will  be  cleared  up  and  that 
field  study  will  attain  to  the  importance  in  the  examination  and  diagnosis  of 
eye  diseases  which  its  great  sensitivity  and  fundamental  relations  entitle 
it  to  have. 


LE  DIAGNOSTIC  ET  LA  MESURE  DES  VICES  DE  RE- 
FRACTION AU  MOYEN  DE  LA  FENTE  STtiNO- 
PEIQUE  ET  DU  CADRAN  HORAIRE 

DOCTEUR  EMILE  JUNES 

de  Sfax,  Tunisia 

Le  diagnostic  et  la  mesure  des  vices  de  refraction  comporte  plusieurs 
methodes  subjectives,  parmi  lesquelles  celle  de  Bonders  est  la  plus 
vivement  recommande'e.  Elle  n'est  pourtant  pas  a  1'abri  de  toute 
critique.  D'une  fagon  generate,  ses  re"sultats,  obtenus  au  prix  de 
tatonnements  parfois  excessifs,  peuvent,  6tre  errone"s.  En  effet, 
1'evaluation  de  1'acuite"  visuelle  maximum,  sur  laquelle  est  fondee 
cette  me'thode,  depend  d'une  appreciation,  somme  toute  assez  dedi- 
cate, de  nuances  visuelles  fort  voisines.  II  faut  done  que  le  sujet 
examine  fasse  preuve  d'une  certaine  finesse  d'intelligence  et  d'une 
attention  soutenue,  ce  qui,  on  le  sait,  n'est  pas  toujours  le  cas.  Dans 
I'astigmatisme,  les  difficulte's  sont  encore  accrues  par  1'emploi  des 
verres  cylindriques.  Aussi  n'utilise-t-on  plus  guere  ces  derniers  que 
pour  verifier,  apr6s  coup,  les  resultats  objectifs  de  la  skiascopie  ou  de 
•  la  keratoscopie. 

Ces  inconvenients  ont  pousse"  certains  ophtalmologistes  a  recher- 
cher  d'autres  precedes  dans  lesquels  1'examen  subjectif  des  vices  de 
refraction  ne  fut  pas  intimement  lie*  a  celui  de  Tacuite  visuelle.  Les 
optometres  construits  d'apres  les  experiences  de  Scheiner  representent 
une  des  tentatives  les  plus  inte"ressantes  qui  aient  ete  faites  dans  cet 
ordre  d'ide"es.  Mais  on  s'accorde  generalement  a  rejeter  ces  appareils 
de  la  pratique  courante  et  a  les  conside"rer  plutot  comme  des  instru- 
ments de  laboratoire.1 

Dans  un  article  public  dans  les  "Archives  d'Ophtalmologie,"2 
nous  avons  montre"  quels  services  pouvait  rendre,  a  ce  meme  point 
de  vue,  une  m^thode  bas^e  sur  1'emploi  simultane"  de  la  fente  ste"n- 

1  Volr  Imbert,  Trait6  de  Physique  Biologique  de  d'Arsonval,  Tome  II,  page 
620. 

2  Diagnostic  de  I'astigmatisme  au  moyen  de  la  fente  stenopeique,  Arch.  d'Oph- 
talmologie, mars,  1921. 

520 


Le  Diagnostic  et  la  Mesure  des  Vices  de  Refraction  521 

opeique  et  du  cadran  horaire.     C'est  de  cette  methode,  de  son  prin- 
cipe,  de  sa  technique  et  de  ses  avantages  que  nous  allons  nous  occuper.1 

PRINCIPE  DE  LA  METHODE 

Abstraction  faite  de  toute  consideration  theorique,  I'examen 
subjectif  des  ametropes,  tel  que  nous  le  pratiquons,  repose  sur  un  fait 
tres  simple.  Lorsqu'on  encadre  un  meridien  corneen  au  moyen  de 
la  fente  ste"nope"ique,  Paspect  du  cadran  horaire,  vu  a  5  metres,  a 
travers  le  meridien  ainsi  isole,  varie  selon  la  maniere  dont  se  corn- 
portent  les  rayons  qui  traversent  ce  meridien.  Si  ces  rayons  ont 
leur  foyer  sur  la  retine  (refraction  emme'trope),  toutes  les  lignes  du 
cadran  sont  vues  avec  la  meme  nettete.  Mais  si  leur  foyer  se  trouve 
reporte  en  avant  ou  en  arriere  de  la  re"  tine  (refraction  ametrope), 
1'aspect  du  cadran  change  et  Poeil  ne  distingue  plus  nettement  qu'un 
seul  diametre  (ou  un  groupe  de  2  ou  3  diametres  immediatement 
voisins) :  celui  qui  est  oriente  dans  le  sens  du  meridien  encadre,  tandis 
que  les  autres  n'offrent  qu'une  apparence  plus  ou  moins  confuse. 
L'on  se  trouve  ainsi  en  presence  d'un  phenomene  optique  comportant 
la  production  de  deux  images,  susceptibles,  a  un  moment  donne, 
de  se  substituer  Fune  a  1'autre. 

Certaines  de  ses  particularites  doivent  etre  bien  mises  en  evidence. 

1  L'emploi  de  la  fente  ste'nopeique  n'est  pas  nouveau.  Quelques  auteurs  1'ont 
d6ja  signale  a  propos  de  1'astigmatisme.  Voici  comment  s'exprime  le  Docteur 
Ch.  Abadie  qui  a  6te,  a  cet  egard,  1'un  des  plus  explicites: 

"Une  fois  la  direction  du  meridien  a  corriger  connue,  un  disque,  perce"  d'une 
fente  et  monte  sur  un  manche,  sera  place"  devant  1'oeil  de  telle  fagon  que  la  fente  du 
disque  soit  parallele  au  m6ridien  deiectueux.  De  cette  fagon,  la  refraction  a 
travers  tous  les  autres  m6ridiens  se  trouve  supprimee  et  1'oeil  ne  voit  plus  qu'a 
travers  celui  qui  doit  6tre  corrige  .  .  .  Pour  determiner  la  myopic  ou  1'hyper- 
m^tropie  de  ce  meridien,  on  essayera  la  se"rie  des  yerres  convexes  ou  concaves 
jusqu'a  ce  qu'on  ait  obtenu  le  maximum  d'acuite"  visuelle.  Le  numero  du  verre 
auquel  on  s'arrete  indique  le  degre  d'am^tropie  du  meridien.  On  aura,  de  la 
sorte,  la  direction  d'un  des  me'ridiens  principaux  et  le  degr6  de  son  anomalie. 

"De  mime,  en  placant  la  fente  du  disque  dans  une  position  perpendiculaire  a 
la  pr6c6dente,  on  determinera  la  refraction  du  deuxieme  meridien  principal." 

(Traite  des  Maladies  des  Yeux,  1884,  T.  ii,  page  376). 

L'on  voudra  bien  remarquer,  apres  cette  lecture:  (1)  Que  le  proc6de,  tel  qu'il 
est  d6crit  par  le  Dr.  Abadie,  est  bas6,  lui  aussi,  sur  la  recherche  de  I'acuite'  visuelle 
maximum.  II  en  re"sulte  que  I'examen  du  sujet  doit  6tre  pratique  au  moyen  d'une 
6chelle  optometrique  et  non  pas,  comme  nous  le  conseillons,  d'un  cadran  horaire; 
(2)  que,  par  suite,  il  n'est  nullement  question,  dans  ce  precede,  de  faire  intervenir 
le  phenomene  optique  qui  sert  de  fondement  a  notre  methode — ph6nomene  pour- 
tant  facile  a  mettre  en  Evidence,  mais  qui  ne  semble  pas  avoir  suffisamment 
attir6  1'attention  des  ophtalmologistes  au  sujet  des  applications  inteiessantes 
auxquelles  il  pouvait  donner  lieu;  (3)  qu'enfin,  et  pour  la  mdme  raison,  la  fente 
stenopeique,  dans  ce  m^me  precede,  est  exclusivement  r^servee  a  1'dtude  de 
I'astigmatisme,  tandis  que  I'emploi  que  nous  en  pre'conisons  est  g6ne>al  et  s'ap- 
plique  aussi  bien  a  I'astigmatisme  qu'aux  vices  de  refraction  du  type  sph^rique. 


522  EMILE  JUNES 

Ces  deux  images  possedent  des  caracteres  parfaitement  tranche's 
et  sont  facilement  opposables  Tune  a  1'autre;  leur  difference  est  assez 
manifesto  pour  qu'elle  ne  puisse  echapper  meme  aux  sujets  les  plus 
bornes.  En  outre,  le  second  aspect  du  cadran,  par  exemple,  qui  se 
produit  tant  que  1'image  de  ce  cadran  ne  se  fait  pas  exactement  sur 
la  ratine,  est  remplace  par  le  premier  d'une  maniere  immediate, 
brusquement  pour  ainsi  dire  (tout  au  moins  en  pratique),  au  moment 
ou  1'ame'tropie  du  meridien  se  trouve  completement  corrigee.  Ajou- 
tons  que  ce  phenomene  optique  se  presente  avec  nettete  meme  avec 
une  acuite  visuelle  notablement  reduite,  pourvu  cependant  que  celle- 
ci  ne  descende  pas  au  dessous  d'une  certaine  limite  et  que  1'oeil  puisse 
distinguer  tout  au  moins  la  disposition  generale  des  lignes  du  cadran. 
L'application  de  ces  donnees  permet  d'effectuer  tres  simplement 
le  diagnostic  et  la  mesure  d'un  vice  de  refraction  quelconque,  a  la 
condition  cependant  qu'une  distinction  soit  etablie  entre  les  ametro- 
pies  du  type  spherique  et  1'astigmatisme.  Dans  le  premier  cas,  1'ex- 
amen  d'un  seul  meridien,  pris  au  hasard,  permet  de  determiner  la 
refraction  generale  de  1'oeil.  Dans  le  second  cas  (il  ne  sera  question 
ici  que  d'astigmatisme  re*gulier),  Pexamen  devra  porter  exclusive- 
ment  sur  les  deux  meridiens  a  refraction  extreme  (meridiens  princi- 
paux) :  ce  qui  ne  peut  se  faire  que  si  leur  orientation  est  deja  connue. 
II  y  aura  done  lieu,  chez  les  astigmates,  de  considerer  un  temps  suple- 
mentaire  dans  lequel  on  recherchera  prealablement  cette  orientation. 

TECHNIQUE  DE  LA  METHODE 

Cette  technique  exige  essentiellement  le  materiel  suivant:  (1)  Un 
cadran  horaire  dont  les  lignes  aient  une  certaine  epaisseur  (type  du 
cadran  de  Green) ;  (2)  une  monture  d'essai  double  et  dont  la  gradua- 
tion soit  identique  a  celle  du  cadran;  (3)  un  disque  noir  perce*  d'une 
fente  stenopeique  et  pouvant  s 'adapter  sur  la  monture  prece'dente;1 
(4)  les  series  convexe  et  concave  des  verres  spheriques.2 

1  Nous  conseillons  de  recourir  aux  lunettes  d'essai  et  de  rejeter,  malgre  tons 
leurs  perfectionnements,  les  disques  stenopeiques  mobiles  a  manche  ou  a  pied. 
II  est  indispensable,  en  effet,  si  le  sujet  est  astigmate,  que,  pendant  tout  le  cours 
de  1'examen,  la  fente  soit  maintenue  dans  une  direction  rigoureusement  parallele 
a  celle  du  meridien  qu'elle  delimite.     C'est  pour  la  m£me  raison  que  nous  con- 
seillons de  toujours  placer  le  disque  dans  la  rainure  posterieure  de  la  lunette;  outre 
que  la  fente,  grace  a  son  rapprochement  de  1'oeil,  encadre  plus  etroitement  le 
me'ridien  examind,  on  6vite  mieux  ainsi  son  d6placement  lore  de  1'emploi  ulterieur 
des  verres. 

2  On  pourrait  avoir  recours  a  un  optometre  du  type  Badal,  muni  d'une  fente 
stenopeique  et  dont  la  photographie  representant  l'6chelle  visuelle  serait  remplacee 
par  celle  d'un  cadran  horaire.     Mais,  pour  la  raison  exposee  dans  la  note  pre- 
cedente,  son  emploi  dans  1'astigmatisme  pourrait  donner  lieu  a  des  erreurs. 


Le  Diagnostic  et  la  Mesure  des  Vices  de  Refraction  523 

On  examine  chaque  oeil  separement.  Le  sujet  etant  place  a  5 
metres  du  cadran  horaire,  on  1'invite  a  definir  1'aspect  de  ce  cadran 
vu  a  1'oeil  nu.  Trois  cas  se  presentent,  selon  que  1'oeil  examine": 
(1)  Ou  bien  distingue  nettement  toutes  les  lignes  du  cadran;  (2)  ou 
bien  ne  distingue  nettement  qu'une  seule  de  ces  lignes  ou  un  petit 
groupe  de  lignes  immediatement  voisines  (pour  la  commodite*  de  la 
description,  nous  designerons  cet  aspect  du  cadran  sous  la  denomina- 
tion de  "phenomene  de  la  ligne  noire");  (3)  ou  bien  ne  distingue 
nettement  aucune  des  lignes  du  cadran. 

La  technique  se  modifie  legerement  suivant  le  cas  considere.  Nous 
1'etudierons,  en  supposant,  une  fois  pour  toutes:  (1)  Que  1'oeil  ex- 
amine presente  une  integrite  absolue  de  ses  milieux  transparents  es 
de  ses  elements  sensoriels;  (2)  que  le  muscle  ciliaire  possede  toute 
son  activite  fonctionnelle. 

PREMIER  CAS — LE  SUJET  DISTINGUE  NETTEMENT  TOUTES  LES 
LIGNES  DU  CADRAN. — L'oeil  examine  n'est  pas  astigmate.  II  peut 
etre  emmetrope,  myope  de  tres  faible  degre  ou  hypermetrope  ac- 
comodant  pour  Finfini.  Nous  envisagerons  successivement :  (1) 
L'encadrement  de  cet  oeil  par  la  f ente  stenopeique ;  (2)  le  diagnostic 
de  son  etat  de  refraction;  (3)  la  mesure,  s'il  y  a  lieu,  de  son  degre 
d'ametropie. 

1.  Mise  en  Place  de  la  Fente  Stenopeique. — L'oeil  est  muni  de  la 
monture  d'essai,  sur  la  rainure  posterieure  de  laquelle  on  adapte  le 
disque  stenopeique.     La  fente  peut  etre  disposee  suivant  une  orienta- 
tion quelconque;   tous  les  meridiens  possedant  le  meme  pouvoir  re- 
fringent,  Ton  n'a,  en  effet,  a  examiner  ici  qu'un  seul  meridien,  pris  au 
hasard. 

2.  Diagnostic  de  I'Etat  de  Refraction. — II  resulte  de  1'aspect  que 
prend  le  cadran  apres  1'application  du  disque  stenopeique. 

Ou  bien  son  aspect  ne  change  pas,  c'est  a  dire  que  toutes  les  lignes 
du  cadran  continuent  a  etre  pergues  avec  la  meme  nettete.  Dans 
ce  cas,  1'oeil  est  emmetrope  ou  hypermetrope.  Plagons  devant  la 
fente  (dans  la  rainure  anterieure  de  la  lunette),  un  verre  convexe  de 
faible  puissance.  Si  1'aspect  du  cadran  reste  le  meme,  c'est  que 
1'oeil  est  hypermetrope;  dans  le  cas  contraire,  si  le  phenomene  de  la 
ligne  noire  se  manifesto,  1'oeil  est  emmetrope. 

Ou  bien  1'aspect  du  cadran  se  modifie:  le  phenomene  de  la  ligne 
noire  apparait.  Dans  ce  cas,  1'oeil  est  myope. 

3.  Mesure  du  Degre  d'Ametropie. — L'oeil  est  myope — L'applica- 
tion  de  la  fente  a  fait  apparaitre  le  phe'nomene  la  ligne  noire. 


524  £MILE  JUNES 

Flagons,  devant  la  fente,  des  verres  concaves  de  degre  croissant.  Le 
verre  le  plus  faible  qui  provoque  la  disparition  du  phe'nomene,  en 
rendant  e"galement  nettes  toutes  les  lignes  du  cadran,  mesure  le  degre 
de  la  myopie. 

L'oeil  est  hyperine" trope. — L'application  du  disque  n'a  pas  modifie 
1'aspect  du  cadran  vu  a  1'oeil  nu.  Faisons  passer,  devant  la  fente,  des 
verres  convexes  de  degre  croissant.  L'un  de  ces  verres  provoque 
1'apparition  de  la  ligne  noire;  celui  qui  le  precede  imme*diatement 
mesure  le  degre"  de  1'hypermetropie. 

DEUXIEME  CAS — LE  SUJET  DISTINGUE  NETTEMENT  UNE  SEULE 
LIGNE  DU  CADRAN  ou  UN  GROUPE  DE  LIGNES  IMMEDIATEMENT 
VOISINES. — L'oeil  est  astigmate.  Son  diagnostic  devra  se  faire  ex- 
clusivement  suivant  les  deux  meridiens  a  refraction  extreme.  Ces 
deux  meridiens  seront  examines  successivement  et,  pour  chacun 
d'eux,  on  determinera:  (1)  Son  orientation;  (2)  son  isolement  au 
moyen  de  la  fente  stenopelque;  (3)  son  e"tat  de  refraction;  (4)  s'il 
y  a  lieu,  le  degre"  de  son  ametropie.  L'exainen  du  premier  meridien 
servira  de  type  a  notre  description. 

1.  Orientation  du  Meridien. — L'astigmate,  place  en  face  du  cadran, 
ne  pergoit  nettement  qu'une  seule  des  lignes  qui  le  composent,  par- 
fois  un  groupe  de  lignes  immediatement  voisines  (phenomene  de  la 
ligne  noire).     Or,  la  direction  de  cette  ligne  se  trouve  etre  precise- 
ment  celle  d'un  meridien  principal.     On  la  releve,  en  lisant,  sur  le 
cadran,  le  degre  qui  lui  correspond. 

2.  Isolement  du   Meridien. — L'oeil   e"tant    muni   de   la    monture 
d'essai,  on  dispose  le  disque  dans  sa  rainure  posterieure,  de  telle  fagon 
que  la  fente  soit  exactement  orientee  suivant  le  degre  indique;1   des 
lors,  on  veillera,  pendant  toute  la  dure"e  de  1'examen,  a  ce  que  cette 
direction  soit  rigoureusement  maintenue. 

3.  fitat  de  Refraction  du  Meridien. — Le  meridien,  ainsi  isole,  peut 
etre  emmetrope,  myope  ou  hypermetrope  accommodant  pour  1'infini. 
Deux  cas  se  presentent. 

Ou  bien,  1'aspect  du  cadran,  vu  a  travers  la  fente  ste'nope'ique,  ne 
change  pas,  c'est  a  dire  que  le  phenomene  de  la  ligne  noire  persiste; 
le  me*ridien  est  myope. 

Ou  bien,  cet  aspect  change;  le  phenomene  de  la  ligne  noire  dis- 
parait  et  toutes  les  lignes  du  cadran  sont  vues  avec  la  meme  nettete : 

1  Si  1'on  ayait  affaire  a  un  groupe  de  deux  lignes  noires,  la  fente  serait  orientee 
suivant  la  bissectrice  de  Tangle  forme'  par  ces  deux  lignes;  si  ce  groupe  com- 
prenait  trois  lignes,  son  orientation  serait  celle  de  la  ligne  intermediate. 


Le  Diagnostic  et  la  Mesure  des  Vices  de  Refraction  525 

le  me'ridien  est  emmetrope  ou  hyperme'trope.  Disposons,  devant 
le  disque,  un  verre  convexe  de  faible  puissance.  Si  le  phe'nomene  de 
la  ligne  noire  reapparait,  on  a  affaire  a  un  me'ridien  emme'trope; 
sinon,  si  toutes  les  lignes  persistent  avec  une  egale  nettete,  le  meridien 
est  hyperme'trope. 

4-  Degre  d'Ametropie  du  Meridien. — Considerons  successivement 
le  cas  d'un  meridien  myope  et  celui  d'un  me'ridien  hyperme'trope: 

Gas  d'un  meridien  myope — La  fente  ste'nopeique  a  laisse"  persister 
le  phe'nomene  de  la  ligne  noire  apparu  a  1'oeil  nu.  Faisons  passer, 
devant  elle,  des  verres  concaves  de  degre  croissant.  Le  verre  le 
plus  faible  qui  provoque  la  disparition  du  phenomene  et  rend  toutes 
les  lignes  du  cadran  egalement  distinctes,  mesure  le  degre"  de  myopie 
du  me'ridien. 

Cas  d'un  me'ridien  hypermetrope. — La  fente  ste'nope'ique  a  fait 
disparaitre  le  phe'nomene  de  la  ligne  noire.  Flagons,  devant  cette 
fente,  des  verres  convexes  de  degre  croissant.  L'un  d'eux  provoque 
la  reapparition  du  phenomene.  Celui  qui  le  precede  imme'diatement 
mesure  le  degre  d'hypermetropie  du  me'ridien. 

Nous  serons  plus  bref  en  ce  qui  concerne  1'examen  du  second 
meridien.  La  fente  sera  disposee  suivant  une  direction  exactement 
perpendiculaire  a  celle  qu'elle  occupait  precedemment  (les  deux 
meridiens  principaux  e"tant,  comme  on  le  sait,  perpendiculaires  entre 
eux).  L'aspect  du  cadran,  Examine  a  travers  la  fente  ainsi  oriente"e, 
nous  permettra,  grace  aux  notions  qui  viennent  d'etre  exposees,  de 
diagnostiquer  1'etat  de  refraction  du  second  me'ridien  et  de  mesurer, 
s'il  y  a  lieu,  son  degre"  d'ame'tropie. 

Comme  on  le  voit,  Pemploi  de  la  fente  ste'nope'ique  et  du  cadran 
horaire  nous  donne  le  moyen  de  mettre  en  evidence  1'un  des  elements 
indispensables  au  diagnostic  de  Fastigmatisme :  la  puissance  diop- 
trique  des  deux  meridiens  principaux.  Des  lors,  connaissant  la  direc- 
tion de  ces  meridiens,  on  peut  etablir  la  formule  ne"cessaire  a  la  pre- 
scription des  verres  correcteurs. 

TROISIEME  CAS — LE  SUJET  NE  DISTINGUE  NETTEMENT  AUCUNE 
DES  LIGNES  DU  CADRAN. — II  s'agit,  dans  ce  cas,  soit  de  myopie, 
soit  d'hypermetropie  accompagnee  d'un  deficit  plus  ou  moins  marque" 
de  raccomodation  pour  1'infini.  1'une  ou  1'autre  pouvant  etre  simple 
ou  compliquee  d'astigmatisme.  Nous  aurons  a  diagnostiquer:  (1) 
La  nature  de  1'ame'tropie ;  (2)  son  degre*. 

1.  Nature  de  I'Ametropie. — On  la  determine  avec  le  seul  secours 
du  cadran  horaire.  Flagons,  devant  1'oeil  examine",  tout  d'abord  les 


526  EMILE 

premiers  verres  de  la  serie  concave.  Si  les  lignes  du  cadran  de- 
viennent  toutes  e"galement  plus  distinctes,  on  a  affaire  a  .de  la  myopie 
simple;  si  1'une  seulement  de  ces  lignes  devient  plus  nette,  c'est  qu'il 
s'agit  d'astigmatisme  compose  myopique  (meridiens  principaux  tous 
deux  myopes);  1'on  note  soigneusement  alors  la  direction  de  cette 
ligne.  Les  verres  concaves  n'ameliorent-ils  pas  la  vision,  Ton  pro- 
cedera  de  la  meme  maniere  avec  les  verres  de  la  serie  convexe ;  ceux- 
ci  nous  feront  savoir  s'il  s'agit  d'hypermetropie  simple  ou  d'astig- 
matisme compose  hyperme'tropique  (meridiens  principaux  tous  deux 
hypermetropes) . — II  est  preferable  de  commencer  par  les  verres 
concaves,  car  les  formes  myopiques  sont  les  plus  frequentes. 

2.  Degre  de  V  Ametropie. — Sa  determination  necessite  1'interven- 
tion  du  disque  stenopeique.  La  mise  en  place  de  la  fente  differe 
selon  que  Ton  est  en  presence  d'une  ametropie  du  type  spherique  ou 
d'astigmatisme.  Dans  le  premier  cas,  la  fente  encadrera  un  meridien 
quelconque,  pris  au  hasard;  dans  le  second  cas,  il  faudra  la  disposer 
successivement  suivant  les  deux  meridiens  principaux. 

Le  meridien  ainsi  encadre  est,  nous  venons  de  le  voir,  myope  ou 
hypermetrope  avec  accommodation  deficiente  pour  Pinfini.  Quelle 
que  soit  la  nature  de  son  ametropie,  la  simple  application  du  disque 
au  devant  de  la  cornee  determine  1'apparition  du  phenomene  de  la 
ligne  noire.1  Le  changement  que  subit  cet  aspect  du  cadran  sous 
1'influence  de  verres  spheriques  surajoutes  permet  de  mesurer  le 
degre  d'ame*tropie  du  meridien. 

Cas  d'un  meridien  myope. — Ici  encore,  le  degre  de  myopie  est 
determine  par  le  verre  concave  le  plus  faible  qui  fait  disparaitre  le 
phenomene  de  la  ligne  noire  en  rendant  toutes  les  lignes  egalement 
nettes. 

Cas  d'un  meridien  hypermetrope. — Faisons  passer,  devant  la  fente 
stenopeique,  des  verres  convexes  de  degre  croissant.  A  un  moment 
donne,  par  suite  d'une  correction  partielle  de  1'hypermetropie,  1'ac- 
comodation  produit  son  plein  effet:  Le  phenomene  de  la  ligne  noire 
disparait  et  toutes  les  lignes  sont  pergues  avec  la  meme  nettete. 
Continuons  a  interposer  des  verres  de  degre  de  plus  en  plus  eleve; 
1'un  d'eux  fera  reapparaitre  le  phenomene;  le  verre  qui  le  precede 
donnera  le  degre  d'hypermetropie  cherche*. 

1  L'apparition  de  cette  ligne  est  immediate  si  le  degre  d'ame'tropie  n'est  pas 
trop  eleve  et  permet  d'entrevoir  tout  au  moins  la  disposition  g£ne"rale  des  lignes  du 
cadran;  dans  le  cas  contraire,  le  phe'nomene  n'apparait  qu'apres  interposition 
d'un  verre  corrigeant  partieilement  cette  am6tropie. 


Le  Diagnostic  et  la  Mesure  des  Vices  de  Refraction  527 

AVANTAGES   DE   LA   METHODE 

Cette  methode  comporte  plusieurs  avantages: 

1.  Elle  n'exige  aucun  outillage  nouveau.     Bien  plus,  elle  simplifie 
1'outillage  existant,  grace  a  la  suppression  des  verres  cylindriques  et 
parce  que  le  cadran  horaire  est  susceptible  d'un  usage  universel, 
convenant  aussi  bien  aux  lettres  qu'aux  illettres  et  a  ceux  dont 
1'ecriture  ne  correspond  pas  au  type  courant  (Arabes,  Russes    .     .     .). 

2.  En  raison  de  la  simplicite  et  de  la  nettete  du  phenomene  optique 
qui  la  caracterise,  elle  permet  un  examen  rapide  et  precis  des  ame- 
tropies,  quels  que  soient  1'etat  de  la  refraction  et  Intelligence  du  sujet 
a  examiner.1 

3.  Sa  superiority  eclate  specialement  a  propos  de  Fastigmatisme. 
A  1'encontre  de  la  methode  des  verres  cylindriques,  nous  avons 
affaire  ici  a  une  methode  permettant  de  determiner,  avec  facilite  et 
de  prime  abord,  ce  vice  de  refraction.2 

4.  Pour  conclure,  nous  dirons  que  cette  methode,  en  ce  qui  con- 
cerne  le  diagnostic  et  la  mesure  des  ametropies,  est  plus  precise  et 
moins  malaisee  a  appliquer  que  la  methode  de  Bonders.3     Nous 
n'hesitons  pas,  en  outre,  a  affirmer  que,  sauf  pour  certains  cas  tres 
particuliers  (simulation,  enfants  trop  jeunes,  diminution  trop  con- 
siderable de  1'acuite  visuelle     .     .     .),  cette  methode  peut  soutenir 
la  comparaison  avec  la  plupart  des  methodes  objectives.     C'est  ainsi 
qu'elle  peut  rendre  les  plus  grands  services  a  tous  ceux  qui  ne  sont 
pas  familiarises  avec  les  difficultes  de  la  skiascopie  ou  qui,  momentane- 
ment,  ne  peuvent  disposer  d'une  installation  appropriee  a  ce  dernier 
mode  d' investigation  (armees  en  campagne,  tournees  ophtalmolo- 
giques  dans  le  bled). 

1  L'existence  d'une  contraction  accomodative,  frequente  chez  les  jeunes  sujets, 
peut  e"tre  une  cause  d'erreur  a  laquelle  on  remediera,  ici  aussi,  par  des  instillations 
d'atrophine. 

2  Ce  qui  rend  si  compliquee  la  determination  de  1'astigmatisme  par  la  seule 
methode  des  verres  cylindriques,  c'est  que,  les  differents  meridiens  de  la  cornee 
laissant  simultanement  passer  les  rayons  lumineux,  1'oeil,  au  cours  du  meme 
examen,  peut  accomoder  tantot  pour  Tun,  tantot  pour  1'autre  des  meridiens 
principaux.     Ici,  par  contre,  du  seul  fait  que  les  rayons  ne  traversent  a  la  fois 
qu'un  seul  meridien,  cette  intervention  d6sordonnee  de  1' accommodation  se  trouve 
supprimee. 

*  Elle  ne  saurait  toutefois  pas  la  remplacer  completement.  A  la  methode  de 
Bonders  est  reserve",  en  effet,  un  role  fort  important  et  qui  lui  est  propre.  Com- 
plement obligatoire  des  autres  m6thodes,  elle  intervient  &  titre  de  contr61e  des 
que  Ton  aura  effectue,  a  1'aide  de  ces  dernieres,  le  diagnostic  et  la  mesure  du  vice 
de  refraction.  Elle  nous  renseigne  alors  sur  1'acuite  visuelle  de  1'oeil  exactement 
corrige  et  nous  fait  connaitre  le  verre  le  mieux  tolere  et  le  plus  utile.  Elle  permet 
ainsi  une  prescription  plus  appropri6e  a  l'6tat  physiologique  du  sujet. 


ANOMALIES  OF  OCULAR  DEVELOPMENT  AND 
PIGMENTATION 

J.  GRAY  CLEGG,  M.D.,  B.S.,  F.R.C.S. 

Manchester,  England 

BILATERAL  SYMMETRIC  CONGENITAL  CORECTOPIA  WITH  IRIDODONESIS 
AND  MlCROCORIA ;  MlCROLENTIS  AND  COLOBOMA  LENTIS 

William  S.,  male,  aged  fifty-eight. 

History. — Always  poor  sight.  Worked  as  stoker  and  engine  tender. 
Could  not  see  enough  to  gain  much  at  school.  One  half -brother- and  two 
half-sisters,  all  by  one  mother.  All  have  good  sight  except  the  brother,  who 
is  short-sighted  and  wears  glasses.  No  other  member  of  family  had  eye 
trouble  except  one  with  squint.  Patient  has  five  daughters -and  one  son. 
All  have  normal  eyes.  Patient  is  of  impression  that  when  a  child  he  was 
brought  to  the  Manchester  Royal  Eye  Hospital  and  was  told  sight  was  wrong 
way  up. 

Sight  got  better  as  grew  older  until  forty-six  or  so,  but  since  then  worse. 
Could  just  read  newspaper  with  the  left  eye  by  holding  near  face  and  screwing 
eyelids  up.  Could  only  see  headings  of  newspaper  with  the  right.  Never 
could  obtain  glasses  to  help. 

Came  under  my  care  about  June,  1921,  because  he  frequently  ran  against 
people  in  street. 

Condition  on  Admission,  September  27,  1921 :  Extrinsic  muscles  act  well. 
Lids,  conjunctivas,  and  lacrimal  passages  normal.  Cornea  clear,  but  a  trifle 
smaller  than  normal.  Diameter,  10  mm.  vertically  by  11  mm.  horizontally. 
Anterior  chambers  rather  deep.  Irides  and  pupils  as  in  sketch.  Plane  of 
irides  flat  and  coronal.  The  tissue  of  the  iris  thin  but  thickened  in  immediate 
neighborhood  of  the  pupils.  Pupils  reacted  definitely  to  light.  Drugs  had 
no  marked  effect  on  the  pupils,  except  that  atropin  alone  brought  about  some 
dilatation,  increasing  the  pupillary  area  to  double  its  ordinary  size. 

It  was  impossible  to  see  through  the  pupils  with  the  ophthalmoscope,  but 
they  lighted  up  well  by  transillumination,  showing  as  small,  irregular  sided 
slits,  the  pupillary  margins  of  the  iris  roughly  dovetailing  their  prominence 
and  fissures  when  contracting. 

With  a  strong  loupe  the  stretched  iris  tissue  appears  as  irregular  alternating 
bands  of  blue  and  brown,  but  the  tissue  surrounding  the  pupil  is  finely  radi- 
ally furrowed,  and  of  a  light  brown  tint.  V.R.E.  =  fingers;  V.L.E.  +  2 
sph.  =  J.  20. 

528 


Anomalies  of  Development  and  Pigmentation 


529 


October  13th:  V.R.E.  +  3  D.  sph.=  J.  20;  V.L.E.,  6/60;  with +  3  D. 
sph.  =  J.  20. 

October  26th:  Iridectomy  inner  side  (Fig.  1). 

October  29th :   Lids  swollen,  good  hole  in  iris,  somewhat  square  in  shape. 

November  2d:  Lens  appeared  in  anterior  chamber  completely  opaque. 
Calcareous,  with  small  coloboma  below. 

November  3d:  Lens  slipped  back  into  vitreous  cavity;  could  not  be  seen 
by  the  ophthalmoscope. 

November  4th:  Lens  again  in  anterior  chamber.  Patient  kept  on  right 
side.  Lens  5  mm.  in  diameter  with  coloboma  below.  Under  a  local  anes- 


7**#l$fF 


Fig.  1. — Bilateral  symmetric  congenital  corectopia  after  operation  on  right  eye. 

thetic  a  section  of  the  cornea  was  made  up  and  out,  Lens  spooned  out.  In 
the  process  the  capsule  was  ruptured  partially.  Whole  drawn  out  by  forceps; 
atropin  instilled. 

November  10th:  Some  swelling  of  lids,  slight  injection,  and  chemosis  of 
the  conjunctiva.  Keratitis  striata.  Fair  anterior  chamber.  Coloboma 
larger  than  before  extraction  of  lens. 

December  3d:  Right  palpebral  fissure  smaller  than  left.    Slight  redness 

of  skin  of  lids.     Merest  trace  of  limbal  injection.     Wound  perfectly  healed. 

Cornea  bright.     Fair  anterior  chamber.     The  new  pupil  is  absolutely  black. 

The  original  pupil  is  almost  closed  by  sphincter  and  shows  as  black,  irregular 

34 


530 


J.  GRAY  CLEGG 


Appearance  of  iris  like  fine  Palate 

brown  velvet,  with  two 
patches  of  brown  jelly  ly- 
ing on  surface. 

Fig.  2. — Melanosis  of  right  eye,  scalp,  cheek,  and  palate. 


Anomalies  of  Development  and  Pigmentation  531 

line  only.    V.R.E.+  9  D.  sph. O  +  2  D.  cyl.  ax.  15°=  6/36;  +  16  D.  sph.O 
+  2  D.  cyl.  ax.  15°  =  J.  8. 

Vitreous  clear.  Disc  is  somewhat  blurred  at  margin.  Staphyloma  pos- 
terior disc  %  diameter  in  width.  Superior  temporal  retinal  veins  tortuous. 
No  other  fundal  lesion.  The  left  field  shows  slight  contraction,  but  the  right 
is  normal.  There  is  no  scotoma.  Tension  normal. 


MELANOSTS  OF  THE  EYE,  SKIN  OF  RIGHT  SIDE  OF  HEAD,  AND 
RIGHT  PALATE 

Ethel  Mary  R.,  female,  aged  twelve. 

History. — One  sister  aged  ten;  one  sister  aged  seven,  all  healthy.  One 
half  brother,  seven  months,  quite  well. 

No  history  of  any  abnormal  pigmentation  in  two  maternal  uncles,  eight 
maternal  aunts,  three  paternal  uncles,  two  paternal  aunts.  Has  numerous 
cousins,  all  well. 

Patient  had  slight  scarlet  fever  and  varicella. 

There  is  an  extensive  patch  of  pigmentation  of  the  skin  of  the  right  side  of 
the  head,  affecting  the  upper  part  of  the  cheek,  the  temple,  and  the  skin  of 
the  scalp,  reaching  nearly  to  the  vertex.  The  density  of  the  pigmentation  is 
not  uniform,  and  it  resembles  the  color  of  a  blue-black  ink-splash.  The 
edges  of  the  area  are  irregular  and  not  sharply  defined.  The  skin  is  not 
swollen  and  does  not  fade  on  pressure.  There  is  no  nevoid  condition. 

A  similar  pigmentation  is  found  on  the  right  palate,  with  indistinct  margins, 
and  a  less  deeply  pigmented  area  is  seen  in  the  mucous  membrane  of  the  right 
cheek.  The  patch  on  side  of  cheek  and  temple  fades  a  little  when  weather 
is  fine,  and  goes  darker  when  wet.  The  pigmentation  was  present  at  birth 
and  has  not  changed.  No  other  abnormal  pigmentation  is  discernible. 
The  right  globe  presents  the  most  striking  feature  of  the  case.  It  is  some- 
what enlarged  and  divergent  to  the  extent  of  some  15  degrees.  The  palpe- 
bral  fissure  is  a  trifle  wider  than  the  left,  exposing  the  sclera  below  for  about 
1  mm.  The  conjunctiva  itself  is  not  affected.  The  ocular  portion  is  free 
from  any  abnormal  adhesion  to  the  episcleral  tissue.  The  latter  presents 
extensive  areas  of  brown-black  pigmentation.  Two  of  the  better  defined 
areas  are  distinctly  swollen  to  the  extent  of  1  mm.,  viz.,  the  large  one  below 
the  cornea  and  a  smaller  one  above.  The  cornea  shows  in  a  small  central 
area  fine  superficial  pitting,  but  it  is  otherwise  clear.  The  anterior  chamber 
is  rather  shallow.  The  surface  of  the  iris  is  a  stippled  dark  brown,  as  seen 
in  the  brown  eyes  of  dark  races.  There  are  two  areas  of  brownish,  gelatinous 
material,  apparently  lying  on  it,  both  of  which  extend  slightly  over  the 
pupillary  margin.  The  anterior  capsule  and  cortex  are  clear.  Some  bluey 
opacity  in  the  nucleus  of  the  lens  is  easily  seen.  No  red  reflection  is  ob- 
tained by  the  ophthalmoscope.  V.  R.  E.:  No  1.  p.  No  lighting  of  pupil  by 
transillumination.  T  +  1. 


532  J.  GRAY  CLEGG 

The  left  eye  is  normal  in  every  respect  and  its  field  good. 

The  thyroid  is  large;  some  thrill  felt  on  pressure  on  gland.  Impairment  of 
resonance  with  some  collapse  of  the  lung  at  the  right  apex,  but  no  evidence  of 
active  disease. 

There  is  a  deep-seated  mass  in  the  right  hypochondrium,  which  is  moder- 
ately tender  on  pressure  (glands?). 

Vascular  and  nervous  systems  normal. 

DISCUSSION 

MR.  E.  TREACHER  COLLINS  (London,  England) :  I  have  been  much  inter- 
ested in  the  subject  of  melanosis  of  the  eye  and  the  appearance  of  the  iris  in 
such  cases.  Some  years  ago  the  late  Dr.  George  Coates  showed  a  case  of  this 
description  in  which  on  high  magnification  of  the  surface  of  the  iris  there  was 
a  very  peculiar  appearance.  It  presented  a  number  of  little  nodular  elevations 
very  much  like  the  elevations  on  a  golf  ball.  At  the  same  meeting  I  was  able 
to  show  a  case  of  melanosis  in  which  the  surface  of  the  iris  presented  a  shaggy 
appearance  which  might  be  compared  to  that  of  an  India  rubber  sponge.  Then 
about  two  years  ago  Dr.  Sterling,  of  Atlanta,  Ga.,  had  a  case  of  melanosis  of 
the  iris  in  which  he  had  occasion  to  remove  a  portion  of  it,  and  he  kindly  sent 
me  the  fragment  of  iris  to  examine  microscopically'.  It  showed  that  on  the 
anterior  surface  there  was  a  marked  hyperplasia  of  the  endothelium  of  the  iris, 
and  this  accounted  for  the  irregularity  of  pigmentation  of  the  surface. 

I  would  like  to  ask  Mr.  Clegg  whether  he  had  examined  the  surface  of  the 
iris  in  his  case  under  high  magnification,  and  if  so  whether  he  found  any  such 
appearance. 

DR.  E.  E.  BLAAUW  (Buffalo,  N.  Y.) :  Mr.  Clegg  has  mentioned  that  the 
extracted  lens  in  the  one  eye  had  a  5-millimeter  dimension.  This  points  to 
Vogt's  conception  of  "embryonal  nucleus"  being  a  definite  stage  in  the  lens 
development,  a  stage  which  can  be  followed  through  man's  complete  life. 

DR.  EDWARD  JACKSON  (Denver,  Col.):  The  anomaly  of  pigmentation, 
apparently  general  and  not  strictly  local,  certainly  on  one  side,  leads  us  back 
to  the  thought  of  the  radical  relation  which  pigmentation  seems  to  have  with 
the  vital  processes  of  development,  the  general  biologic  processes.  It  sug- 
gested to  my  mind,  on  reading  Mr.  Clegg's  case,  that  probably  in  that  eye 
would  be  found  some  other  radical  departures  which  would  account  for  the 
complete  blindness.  The  suggestion  made  that  possibly  it  is  going  on  to 
tumor  development,  sarcoma  of  the  eye — that  is  a  possibility  from  the  doubt- 
ful rise  of  tension — gives  an  obvious  explanation;  but  even  such  a  development 
may  be  associated  with  the  radical  connection  between  pigmentation  and  the 
development  of  organs  that  normally  contain  pigment. 

MR.  J.  GRAY  CLEGG  (closing) :  In  reply  to  Mr.  Collins,  I  would  say  that  the 
iris  under  strong  magnification  presented  the  appearance  of  very  fine  dark 
brown  velvet,  and  lying  on  the  iris  near  the  pupillary  margins  were  two  gelati- 
nous, flattened,  irregular  membranes,  extending  on  to  the  pupil  itself. 


LOS  MERCURIALES,  EL  SALVARSAN  Y  SUS  DERI- 
VADOS  EN  EL  TRATAMIENTO  DE  LAS  FORMAS 
GRAVES  DE  CONJUNTIVITIS  Y  QUERATITIS 
ECZEMATOSAS 

DR.  ANTONIO  TORRES  ESTRADA 

Ex-Jefe  de  Clinica  Oftalmologica  en  Escuela  National  de  Altos  Estudios,  Medico  del 

Hospital  Oftalmologico  de  Nuestra  Sar.  de  la  Luz.     Oculista  de  la  Casa  de 

Nifios  Exp6sitos  y  del  Dispensario  del  Servicio  Higienico  Escolar,  en 

la  Ciudad  de  Mexico,  D.  P.,  Rep.  Mexicana 

La  conjuntivitis  eczematosa,  conocida  tambien  con  los  nombres 
de  flictenular,  impetiginosa,  estrumosa,  vascular,  oftalmia  linfatica,  y 
recientemente  con  el  nombre  de  conjuntivitis  tuber culosa,  es  sin  duda 
una  de  las  enfermedades  que  se  presentan  con  mds  frecuencia  al 
oftalmologo.  La  gran  mayorfa  de  los  casos  corresponden  a  formas 
benignas,  que  ceden  con  relativa  facilidad  al  tratamiento  clasico; 
pero  tambien,  con  bastante  frecuencia,  se  presentan  formas  graves 
cuya  evolucion  cronica,  su  tenaz  reincidencia  y  la  rebeldia  a  todo 
tratamiento,  constituyen  un  verdadero  problema  para  el  me'dico  tra- 
tante.  En  cuanto  a  las  consecuencias  de  estas  formas  graves  son 
dignas  de  tomarse  en  consideration  y  de  temerse  por  los  dafios,  a 
veces  irreparables,  que  producen  en  la  cornea,  consistentes  en  panus, 
nefelios,  infiltraciones>  esclerosis  y  leucomas,  con  o  sin  enclavamiento 
del  iris.  En  efecto,  la  participation  de  la  cornea  en  las  formas  graves 
es  constante  y  de  aqui  que  los  sintomas  sean  tan  molestos  y  tan 
alarmantes  y  las  consecuencias  tan  severas. 

Esta  enfermedad,  peculiar  a  los  nifios  de  3  d  15  afios,  encierra  hasta 
la  fecha  el  misterio  mas  complete  sobre  su  etiologia.  En  verdad  pocos 
puntos  hay  en  Medicina  tan  obscuros  como  el  presente,  en  el  que  la 
tenacidad  y  laboriosidad  de  los  investigadores  ha  fracasada.  La 
literatura  sobre  el  tema  es  enorme,  y  por  lo  tanto  solo  me  limitare"  a 
hacer  una  breve  exposition  de  las  ideas  y  de  los  hechos  mas  cul- 
minantes,  asi  como  de  las  opiniones  mas  autorizadas. 

Las  causas  hasta  ahora  senaladas  pueden  clasisncarse  de  la  siguiente 
manera:  A.  Causas  Constitucionales;  B.  Causas  toxicas;  C.  Causas 
microbianas;  D.  Causas  parasitarias,  y  E.  Causas  neurotroficas. 

533 


534  ANTONIO  TORRES  ESTRADA 

(A)  Desde  hace  muchos  anos  se  ha  atribuido  al  terreno  un  papel 
preponderante  en  esta  enfermedad,  de  aqui  los  nombres  de  conjun- 
tivitis  escrofulosa,   estrumosa,   oftalmia  linfatica,   que  ha  recibido 
desde  antano;  en  efecto,  desde  entonces  se  habfa  visto  que  los  por- 
tadores  de  ella  eran  en  su  mayorfa  individuos  escrofulosos,  cuya  cir- 
cunstancia  hizo  que  se  llegara  a  considerar  la  presencia  de  esta  con- 
juntivitis  como  el  signo  mas  eficaz  y  constante  del  temperament o 
linfatico. 

La  alimentacion  deficiente,  las  malas  condiciones  higienicas,  la 
dentition  y  la  convalecencia  de  las  enfermedades  infecciosas  agudas, 
han  sido  otras  tantas  causas  invocadas,  cuya  accion  se  refleja  directa- 
mente  sobre  el  terreno. 

(B)  Burns,  Colombo,  etc.,  han  senalado  entre  las  causas  de  este 
grupo  la  autointoxication  por  retention  de  materias  ester corales.1 
Turner,  en  un  estudio  sobre  la  etiologia  de  esta  enfermedad,  ha  senalado 
como  causa  la  toxemia,  debida  principalmente  a  trastornos  depen- 
dientes  del  aparato  respiratorio :  adenoides,  hipertrofias  amigdalinas 
y  de  los  cornetes  nasales;   asi  como  infecciones  de  la  nariz  y  de  los 
senos  anexos,  cu-yos  trastornos,  a  su  vez,  los  subordina  a  la  autoin- 
toxicacion gastro  intestinal.2 

(C)  Contra  la  opinion  casi  unanime  de  los  oftalmologos,  Leber  y 
Sattler,  Gifford  y  otros  investigadores,  han  atribuido  esta  enfermedad 
al  estafilococo,  que  han  logrado  aislar  de  la  secretion  conjuntival  de 
algunos  enfermos;  mas  seme j  antes  ideas  no  han  sido  admitidas  y  la 
interpretation  general  que  se  ha  dado  a  dichos  hallazgos,  es  considerar 
la  presencia  de  tales  germenes  como  ocasional  y  no  como  causal.    En 
efecto,  contra  la  posibilidad  de  una  causa  microbiana,  estan  las  experi- 
encias  de  Terrien,  quien  ha  inyectado  en  la  camara  anterior  de  monos, 
conejos  y  cuyos,  diversos  productos  obtenidos  de  las  flictenas,  sin  haber 
logrado   ninguna   inoculation.3     Por   otra   parte,    Saemisch,    quien 
designo  la  enfermedad  con  el  nombre  de  conjuntivitis  flictenular,  llego 
tambien,  por  una  serie  de  investigaciones,  a  la  conclusion  de  su  no 
inoculabilidad.    Los  trabajos  en  este  sentido  han  sido  numerosos  y 
todos  convergen  hacia  la  misma  conclusion. 

Axenfeld,  Dor,  Weckers  y  algunos  otros  oftalmologos,  atribuyen  la 
enfermedad  a  la  accion  debilitada  de  las  toxinas  tuberculosas,  cuyo 
origen  seria  habitualmente  algun  foco  tuberculoso  distante  del  ojo, 
pulmonar,  oseo,  ganglionar,  etc.,  Wolff  ha  lanzado  la  teorla  de  que  las 
flictenas  no  serian  sino  una  manifestation  anafildctica  de  la  conjuntiva, 
consistente  en  una  hipersensibilidad  de  ella  a  las  toxinas  tuberculosas 


El  Tratamiento  de  las  Formas  Graves  de  Conjuntivitis         535 

atenuadas,  procedentes  habitualmente  de  algun  foco  ganglionar  del 
cuello  y  supone,  que  el  ojo  mismo,  haya  sufrido  con  anterioridad  algun 
padecimiento  bacilar,  del  cual  ha  sanado  por  los  procesos  naturales.4 

Gibson  en  92  casos  de  conjuntivitis  flictenular  haencontrado  90  con 
von  Pirquet  positive  y  ha  logrado  producir  flictenas  en  conejos  tuber- 
culosos  mediante  la  instilacion  de  tuberculina  en  los  fondos  de  saco 
conjuntivales.5  Weckers  en  55  casos  encontro  51  con  reaccion  positiva 
a,  la  misma  prueba."  Wesseley  sefiala  un  95  por  %.7  Kollner  ha  estu- 
diado  140  casos  de  la  enfermedad  con  relacion  a  diversas  manifesta- 
ciones  tuberculosas  de  que  eran  portadores  los  enfermos,  y  encontro 
una  relacion  entre  la  evolucion  de  estas  y  la  enfermedad  ocular.8  En 
Mexico  Fernandez  MacGregor  sefiala  un  98%  de  von  Pirquet  posi- 
tive.9 Pero  en  contra  de  estos  datos  positives  hay  que  senalar  otros 
diametralmente  opuestos.  Asi,  el  Dr.  Pacheco  Luna  de  Guatemala 
ha  declarado  que,  tanto  los  examenes  radiologicos  como  las  pruebas  de 
von  Pirquet,  han  sido  constantemente  negativas.10  Burnett  ha  encon- 
trado  una  proporcion  muy  inferior  a  las  senaladas,  y  niega  que  haya 
una  relacion  de  causa  a  efecto  entre  la  enfermedad  y  la  tuberculosis.11 
Igualmente  opina  Morax  a  este  respecto.12 

Por  mi  parte  puedo  anadir  que  en  compania  del  Dr.  Daniel  M. 
Velez  he  practicado  la  prueba  de  Calmette  en  varios  ninos  de  la  Casa 
de  Expositos  de  Mexico  y  pude  observar,  contra  lo  que  me  espera, 
que  aquellos  que  habian  padecido  poco  antes  de  conjuntivitis  flicte- 
nular, dieron  constantemente  una  reaccion  negativa.13 

(D)  Chevalereau,  Axenfeld,  Pacheco  Luna,  y  algunos  mas,  han  indi- 
«ado  la  coincidencia  de  esta  enfermedad  con  la  existencia  de  otiriasis 
en  los  ninos  portadores  de  la  enfermedad,  y  atribuyen  la  causa  a  la 
accion  toxica  de  la  saliva  del  parasito  que  es  introducida  en  el  mo- 
mento  de  la  picadura.14 

Ademas  de  los  piojos  han  sido  considerados  como  causa  de  esta  con- 
juntivitis, los  oxiuros,  entre  otros  autores  por  el  Dr.  Andrade  de 
Brasil,  quien  ha  logrado  producir  experimentalmente  la  enfermedad 
•en  el  cachorro,  por  instilacion  en  la  conjuntiva,  del  liquido  perienterico 
de  los  expresados  vermes.15 

(E)  Se  ha  pensado  que  esta  enfermedad  tiene  alguna  analogia  con  el 
herpes  zona,  lo  que  ha  recibido  confirmacion  por  el  hecho  real  de  que 
las  partes  preferentemente   afectadas   en   la  cornea,   corresponden 
frecuentemente  a   las  terminaciones  nerviosas,  lo  que  justifica  en 
«ierto  modo  la  sintomatalogia  tan  aparatosa  de  algunos  casos. 

De  lo  anteriormente  expresado  se  deduce  que  hasta  la  fecha  no  hay 


536  ANTONIO  TORRES  ESTRADA 

en  definitiva  una  causa  a  que  atribuir  la  enfermedad,  cuya  etiologfa 
queda  aun  por  establecerse ;  pero  pueden  asentarse  tres  hechos  per- 
fectamente  probados  y  generalmente  admitidos: 

1.  La  enfermedad  se  encuentra  habitualmente  en  ninos  estrumosos; 
aunque  puede  presentarse  en  algunos  de  constitucion  aparentemente 
sana. 

2.  Tiene  marcada  relacion  con  las  lesiones  impetiginosas  de  la 
nariz,  de  la  cara  y  aun  de  otras  regiones  del  cuerpo;  por  lo  que  le  viene 
los  nombres  de  eczematosa,  impetiginosa  y  pustulosa. 

3.  Que  es  amicrobiana  y  por  lo  tanto  no  inoculable. 

Por  mi  parte  puedo  senalar  un  hecho  mas  que  hasta  la  fecha  no  ha 
merecido  reparo,  o  bien  que  ha  sido  negado  y  es  su  frecuencia  en  ninos 
heredo  sifiliticos  comprobados. 

En  efecto,  no  alcanzo  a  comprender,  como  siendo  relativamente 
grande  el  niimero  de  ninos  afectados  de  esta  enfermedad,  que  pre- 
sentan  al  mismo  tiempo  signos  o  estigmas  evidentes  y  aun  culminantes 
de  dicha  infeccion,  no  hay  a  llamado  la  atencion  de  los  investigadores. 
Sus  pesquizas  no  se  han  orientado  en  este  sentido  y,  en  cambio,  si  han 
sido  de  preferencia  sobre  la  tuberculosis,  siendo  esta  infeccion  mas 
discreta  y  mas  dificil  de  comprobar  por  tener  que  valerse,  casi  de  una 
manera  exclusiva,  de  medios  de  laboratorio. 

No  solo  esta  enfermedad  es  freciiente  en  los  ninos  heredo  sifiliticos, 
sino  que  la  mayor  parte  de  las  veces  que  la  he  visto  en  los  adultos,  se 
trataba  de  sujetos  portadores  de  sifilis.  Por  otra  parte,  no  es  extrano 
observar  formas  asociadas  de  esta  enfermedad  con  alguna  otra  mani- 
festacion  netamente  espedfica,  como  la  de  una  queratitis  intersticial, 
una  escleritis  profunda,  una  iridociclitis,  etc.,  dates  sobre  los  cuales 
tampoco  se  ha  hecho  la  mencion  debida  y  apenas  si  Wecker  y  Landolt, 
mencionan  en  su  obra,  la  asociacion  de  la  conjuntivitis  eczematosa  con 
las  epiescleritis.16 

Esto  no  quiere  decir  que  senale  de  una  manera  categorica  a  la  sifilis 
como  causa  de  la  conjuntivitis  eczematosa;  pues  carezco  hasta  estos 
mementos  de  las  pruebas  y  los  fundamentos  necesarios;  pero  como 
quiera  que  he  sido  uno  de  los  primeros  en  mencionar  esta  causa 
volvere  a  tratar  del  asunto  al  final  de  este  trabajo. 

TRATAMIENTO  POR  LOS  MERCURIALES 

Todos  los  autores  estan  conformes  en  que  los  mercuriales  en  forma 
de  colirios  son  especfficos  contra  esta  enfermedad,  y  desde  hace 
mucho  tiempo  se  vienen  prescribiendo.  El  calomel  y  el  6xido  amarillo 


El  Tratamiento  de  las  Formas  Graves  de  Conjuntivitis         537 

de  mercuric  recientemente  precipitado,  han  sido  los  dos  medica- 
mentos  mas  puestos  en  boga;  tambien  el  bicloruro  de  mercuric,  el 
cinabrio  y  el  oxide  rojo,  han  sido  usados,  aunque  menos  extensamente 
que  los  anteriores. 

Con  relacion  a  la  manera  como  obran  estas  substancias,  nada  se 
sabe;  algunos  creen  que  es  debido  a  la  descomposicion  lenta  que 
sufren  en  presencia  de  las  Mgrimas,  y  otros  les  han  atribuido  una  action 
puramente  mecanica,  que  experiencias  posteriores  han  vehido  a  des- 
mentir. 

Algunos  autores  han  usado  las  sales  de  plata,  como  el  argirol  y  el 
protargol,  pero  su  accion  es  indudablemente  inferior  a  la  de  los  mer- 
curiales. 

El  Dr.  Menacho  recomienda  el  uso  de  colirios  con  tanino;  pero  per- 
sonalmente  me  he  convencido  de  su  inferioridad  con  el  calomel. 

Por  ultimo  Colleman,  Wolff,  etc.,  aplican  los  rayos  X  asegurando 
buenos  resultados.  Este  ultimo  autor  no  solo  ha  logrado  mejoria  en 
las  lesiones  oculares,  sino  que  aun  en  las  de  los  ganglios  del  cuello,  y  usa 
para  la  aplicacion  ocular  4  unidades  H.17 

Por  mi  parte  puedo  decir  que  uso  un  colirio  de  calomel  a  10  %  en 
suspension  en  vaselina  liquida,  del  que  estoy  muy  satisfecho. 

Como  tratamiento  general  los  cldsicos  aconsejan  el  aseo,  la  buena 
alimentacion,  buena  ventilaci6n  y  toda  clase  de  preceptos  higienicos 
encaminados  a  mejorar  la  salud  del  paciente.  Ademas  indican  alguna 
medicacion  tonica  o  antiescrofulosa,  como  los  glicerofosfatos,  el  aceite 
de  higado  de  bacalao,  el  iodo,  etc. 

Hasta  la  fecha  no  se  ha  mencionado  un  tratamiento  general,  que  obre 
de  una  manera  energica  y  eficaz  sobre  la  evolucion  del  padecimiento 
ocular,  de  que  me  vengo  ocupando,  como  obraria  el  tratamiento  espe- 
cifico  en  una  iritis  o  en  una  coroiditis  de  origen  sifilitico.  En  las 
querato  conjuntivitis  flictenulares  de  forma  grave,  tanto  el  trata- 
miento local  como  el  general  hasta  ahora  aconsejados,  son  ineficaces, 
pues  hay  casos  en  que  la  enfermedad  se  prolonga  indennidamente  y 
que  si  curan,  es  expontaneamente,  cuando  los  medios  naturales  tienden 
a  hacerlos  regresar.  El  resultado  de  esta  evolucion  tiene  sobre  la 
corena  las  fatales  consecuencias  que  antes  he  senalado,  y  no  siendo  aun 
bastante,  queda  el  enfermo  constantemente  propenso  a  recaer  en  su 
enfermedad. 

Desde  hace  seis  anos  pude  accidentalmente  darme  cuenta  de  que  el 
mercuric  introducido  al  interior  del  organismo  se  mostraba  eficaz 


538  ANTONIO  TORRES  ESTRADA 

contra  la  enfermedad,  determinando  una  accion  decididamente  favora- 
ble sobre  la  evolucion  de  los  casos  mas  severos. 

Hasta  ahora  el  tratamiento  general  por  el  mercurio  en  este  padeci- 
miento  no  ha  sido  men.cionado,  con  excepcion  de  Bruns,  quien  reciente- 
mente  e  independientemente  de  mi,  lo  ha  manifest  ado.18 

Posteriormente,  como  se  verd  en  el  curso  de  este  trabajo,  he  usado 
con  e"xito  aun  mayor  los  derivados  del  salvarsan,  a  cuya  circunstancias 
debo  el  honor  de  trazar  estas  lineas. 

Me  creo  en  la  obligacion  de  decir  como  llegue  al  conocimiento  de 
estos  hechos,  y  por  lo  tanto  transcribe  la  siguiente  nota  clinica  que  f  ue 
para  mi  de  grandes  ensenanzas : 

El  ano  de  1915,  atendia  de  queratitis  parenquimatosa  a  un  nifio,  en 
quien  la  sifilis  estaba  fuera  de  toda  duda,  a  juzgar'por  los  estigmas  de 
que  era  portado.  Al  mismo  tiempo  una  hermanita,  cuatro  afios 
mayor  que  el,  habia  sido  internada  en  un  sanatorio  de  esta  ciudad, 
para  ser  tratada  de  multiples  y  enormes  ganglios  infartados  del  cuello. 
Se  le  practice  la  extirpacion  de  los  ganglios  estrumosos;  pero  la  opera- 
cion  f  ue  seguida  del  f  racaso  mas  complete :  algunos  ganglios  sanos  que 
quedaron,  a  su  vez  se  infarataron;  el  cuello  en  general  estaba  invadido 
de  una  enorme  empastamiento  y  presentaba  una  rubicundez  violacea  ; 
las  heridas  operatorias  se  habian  retrasado  en  cicatrizar  y  secretaban 
una  serosidad  espesa  que  se  secaba  f ormando  costras ;  la  deglucion  era 
muy  dificil;  los  movimientos  del  cuello  eran  casi  imposibles  y  la  en- 
fermita  apenas  si  dormitaba  reclinada  entre  almohadones.  La  desnu- 
tricion  cada  dia  se  acentuaba  y  el  caso  llego  a  ser  tan  alarmante  que 
se  abrigaron  los  temores  de  un  desenlace  fatal. 

En  los  dias  en  que  se  iniciaba  esta  gravedad  aprecieron  en  un  ojo 
varias  flictenas,  le  hice  una  visita  a  la  paciente  y  recete  un  colirio  con 
calomel ;  pero  la  enfermedad  ocular  se  empeoraba  al  mismo  tiempo  que 
el  estado  general.  Por  ultimo  la  enfermita  fue  trasladada  a  su  domici- 
lio  con  la  idea  de  que  fuera  a  morir  en  el  seno  de  su  familia.  Le  prac- 
tique  una  segunda  visita  y  entonces,  en  un  momento  de  dolor  en  que 
abrio  demesuradamente  su  boca,  pude  observar  que  presentaba  unos 
dientes  de  Hutchinson  enteramente  tipicos  y  una  vobeda  paltina 
ojival,  cuyos  datos,  unidos  a  la  queratitis  intersticial  del  nino,  y  algunos 
otros  que  pude  recoger  por  el  interrogatorio,  me  hicieron  recordar  la 
expresion  inmortal  de  Fournier:  "La  escrofula  es  un  escrofulato  de 
verole."  En  el  acto  concebf  la  esperanza  de  que  un  tratamiento  espe- 
cifico  mejoraria  a  aquella  nina  tan  gravemente  enferma,  y  ese  mismo 
dia  le  aplique"  una  inyeccion  intravenosa  de  cianur  de  mercurio  de 


El  Tratamiento  de  las  Formas  Graves  de  Conjuntivitis         539 

0.01.    Despues  de  ocho  inyecciones,  el  resultado  era  verdaderamente 
milagroso:   Las  heridas  operatorias  habian  cicatrizado;   el  empasta- 


Ano  de  1921 

Casa  de  Ninos  Exp6sitos. — Datos  relatives  al  ntimero  de  ninos  enfermos  de  conj. 
flictenular  y  a  la  existencia  mensual 

miento  del  cuello  habia  desaparecido ;  la  enferma  dormia  y  comf a,  con 
lo  que  recobraba  visiblemente  fuerzas  y  animo.  En  cuanto  a  la 
Iesi6n  ocular,  que  se  habfa  declarado  tan  revelde  al  tratamiento  local, 


540 


ANTONIO  TORRES  ESTRADA 


evoluciono  de  una  manera  tanto  o  mds  admirable  que  el  estado  general 
de  la  enferma. 


1      / 


Ano  de  1920 

Casa  de  Ninos  Exp6sitos. — Datos  relatives  al  niimero  de  ninos  enfermos  de  conj. 
flictenular  y  a  la  existencia  mensual 


Poco  tiempo  despues  se  me  presento  otro  caso  de  conjuntivitis 
flictenular  de  mediana  intensidad,  en  una  niiia  con  datos  negatives  de 
heredo  sffilis,  pero  muy  revelde  al  tratamiento  local,  y  vivas  como 


El  Tratamiento  de  las  Formas  Graves  de  Conjuntivitis         541 

tenia  las  ensenanzas  del  caso  anterior,  no  vacile"  en  inyectar  en  la 
region  glutea  una  solucion  de  0.01  de  cianuro  de  mercuric.    Al  dfa 


Ano  de  1919 

Casa  de  Ninos  Exp6sitos. — Datos  relatives  al  niimero  de  nifios  enfermos  de  conj. 
flictenular  y  a  la  existencia  mensual 


siguiente  habfa  una  notable  mejoria,  obteniendose  una  curacion  com- 
pleta  mediante  dos  inyecciones  mds. 

Desde  entonces  comence  a  usar  el  mercurio  como  tratamiento 


542  ANTONIO  TORRES  ESTRADA 

general  en  los  casos  de  conjuntivitis  eczematosas,  obteniendo  cada  vez 
resultados  altamente  satisfactorios.  Pero  como  en  la  mayor  parte  de 
los  casos  se  trata  de  ninos,  repugna  hacerlos  sufrir  por  las  inyecciones 
intramusculares  de  sales  hidrargiricas,  o  bien  por  que  se  dificulta  sobre 
manera  la  inyecci6n  intravenosa,  me  he  decidido  por  las  fricciones  de 
unguento  mercurial,  con  no  menos  buenos  resultados. 

Este  tratamiento  es  el  que  uso  en  la  clientela  de  hospital,  en  el 
dispensario  del  Servicio  Higie"nico  Escolar  y  en  la  Casa  de  Ninos 
Expositos. 

Acompano  tres  grdficas  con  datos  tornados  de  la  Casa  de  Ninos 
Expositos,  en  las  que  estdn  expresos  la  existencia  total  de  ninos  en 
cada  mes  y  el  numero  de  enfermos  de  conjuntivitis  eczematosa.  La 
primera,  que  corresponde  al  ano  de  1919,  indica  un  numero  muy  alto 
de  enfermos,  coincidiendo  con  la  ausencia  del  tratamiento  mercurial. 
La  del  ano  de  1920,  epoca  en  que  me  hice  cargo  del  Servicio,  arroja  ya 
una  disminucion  apreciable  del  numero  de  casos,  debido  a  que  los 
pacientes  comenzaron  a  ser  tratados  por  las  fricciones  mercuriales. 
La  grdfica  del  presente  ano,  comparada  con  las  anteriores,  sefiala  una 
desproporcion  enorme,  aun  teniendo  en  cuenta  que  el  numero  de 
ninos  ha  sido  menor  que  en  los  afios  anteriores. 

El  resultado  del  tratamiento  mercurial  sobre  el  padecimiento  de  que 
me  vengo  ocupando,  no  puede  ser  mds  ostencible.  La  disminucion 
gradual  que  se  ha  conseguido,  la  atribuyo  a  que  la  mayor  parte  de  estos 
ninos  tienen  frecuentemente  padecimientos  nasales  impetiginosos,  que 
tambien  mejoran  rdpidamente  con  el  tratamiento  mercurial,  y  algunos 
son  francamente  heredo  especificos,  lo  que  me  ha  hecho  insistir  con 
relativa  frecuencia  en  el ;  y  no  solo  se  ha  logrado  la  reduccion  senalada 
en  el  numero  de  casos,  sino  que  cuando  estos  se  han  llegado  a  presentar, 
es  de  una  manera  esporddica  y  han  sido  de  una  benignidad  notable. 
Como  confirmacion  a  este  dato  puedo  manifestar  que  en  el  curso  del 
presente  ano,  los  casos  graves  no  han  excedido  de  dos. 

TRATAMIENTO  POR  EL  ARSENOBENZOL  Y  Sus  DERIVADOS 
La  accion  terape't'ca  energica  del  mercuric  en  el  tratamiento  de  los 
casos  graves,  asi  como  la  frecuencia  de  algunos  estigmas,  o  por  lo 
menos  indicios  de  sffilis  en  los  pacientes,  me  hicieron  probar  otros 
agentes  antisifilfticos  y  no  vacile"  en  inyectar  dosis  de  los  derivados  del 
arsenobenzol,  siendo  el  resultado  el  mds  alhagador  y  sorprendente  que 
se  pudiera  esperar,  pues  su  accion  supera  notablemente  a  la  ya 
grande  abtenida  por  los  mercuriales. 


El  Tratamiento  de  las  Formas  Graves  de  Conjuntivitis         543 

Los  casos  clinicos  que  a  continuacion  relate,  dardn  una  idea  clara 
de  esta  terapeutica. 

A.  G.  de  L.  Nina  de  seis  afios.  Constitucion  debil  y  muy  delicada.  Su 
padre  murio  hace  cuatro  anos  de  tuberculosis  pulmonar.  No  hay  mas  ante- 
cedentes  de  tuberculosis  en  la  familia.  A  la  edad  de  cuatro  anos,  la  pequena 
tuvo  un  padecimiento  gastro-intestinal  muy  revelde.  No  presenta  estigmas 
ni  antecedentes  de  heredo  sifilis.  No  presenta  ganglios  infartados,  ni  cicatrices 
en  el  cuello.  Hace  un  ano  cuatro  meses  viene  padeciendo  de  una  querato  con- 
juntivitis  eczematosa  en  ambos  ojos,  con  pequenas  mtermitencias  y  mas 
acentuada  en  el  ojo  derecho.  El  examen  revelo  en  este  ojo  multiples  flictenas 
en  el  limbo  y  algunas  en  la  cornea  y  e"sta  cubierta  de  panus.  La  fotofobia  era 
intensa  y  los  parpados  presentaban  escoriaciones  en  el  dngulo  externo.  El 
ojo  izquierdo  presentaba  algunas  pequenas  flictenas  en  el  limbo  y  algunos 
nefelios,  que  testificaban  ataques  anteriores  de  la  enfermedad  y  la  participa- 
cion  de  la  cornea  en  ellos.  La  prueba  de  von  Pirquet  fu6  negativa.  Trata- 
miento: colirio  de  calomel  y  aplicacion  de  una  dosis  de  0.10  de  Muscbarsenol 
Corbiere,  logrdndose  dias  despu^s  una  mejoria  muy  apreciable.  Seis  dlas  mds 
tarde  aplique  una  dosis  de  0.15  y  el  alivio  se  acentuo  mds.  Al  cabo  de  tres  dfas 
de  la  tercera  inyeccion,  que  tambien  fue  de  0.15,  ya  no  se  veian  las  flictenas; 
el  panus  habia  desaparecido  a  la  simple  vista  y  s61o  la  lente  revelaba  toda — via 
algunos  vasos;  lo  unico  que  aun  persistfa,  pero  muy  mejoradas,  eran  las 
escoriaciones  de  los  parpados.  Fueron  aplicadas  dos  inyecciones  mds  de  la 
misma  dosis  y  se  obtuvo  una  curacion  completa,  mejorando  al  mismo 
tiempo  el  estado  general  de  la  nina. 

C.  N.  de  15  anos.  Constitucion  debil.  Presenta  antecedentes  hereditarios 
que  suponen  la  sifilis.  Nulos  respecto  a  la  tuberculosis  y  el  von  Pirquet  nega- 
tive. No  presenta  infartos  ganglionares  del  cuello.  No  hay  estigmas  de 
heredo  sifilis,  pero  la  reaction  de  Wassermann  es  dos  veces  m£s.  Desde  su 
infancia  viene  padeciendo  ataques  de  conjuntivitis  eczematosa  en  ambos  ojos 
y  de  una  manera  mds  insistente  en  el  ojo  izquierdo,  en  los  dos  ultimos  anos. 
El  examen  revelo  numerosas  flictenas  conjuntivales  y  corneales  en  ese  ojo; 
una  ulcera  en  el  limbo,  como  a  las  9  h/;  panus  y  algunas  infiltraciones  en  la 
cornea.  La  fotofobia  era  muy  intensa.  La  vision  estaba  muy  disminuida,  al 
grado  de  no  ver  si  no  el  bulto  de  la  mano. 

Tratamiento:  colirio  de  calomel,  atropina  y  vendaje.  Previo  reconoci- 
miento  de  orina,  se  le  aplico  una  dosis  de  0.15  de  neosalvarsan  por  la  via  endo- 
venosa,  desapareciendo  dias  ma's  tarde,  la  fotofobia  y  pudie'ndose  dejar  el  ojo 
al  descubierto  por  haber  cicatrizado  la  ulcera.  El  medicamento  se  fu6  inyec- 
tando  en  serie  cada  seis  dias  hasta  llegar  a  la  dosis  de  0.45,  y  se  obtuvo 
despue's  de  cuatro  inyecciones  un  alivio  tan  complete,  que  la  agudeza  visual 
llego;  a  0.3.  En  la  cornea  persistian,  sin  embargo,  nefelios  y  algunas  in- 
filtraciones gruesas,  muy  blancas  y  vascularizadas. 

J.  S.  Sexo  femenino  de  19  anos.     Constituci6n  muy  debil  y  delicada.     Ha 


544  ANTONIO  TORRES  ESTRADA 

tenido  quince  hermanos,  de  los  cuales  ocho  han  muerto,  tres  antes  de  dos 
meses  de  nacidos  y  los  cinco  restantes,  de  pocos  afios.  Uno  de  los  que  viven  es 
loco.  Otro  es  marcadamente  escrofuloso.  La  madre  padece  de  epilepsia.  El 
padre  vive  y  es  aparentemente  sano.  La  paciente  no  presenta  infartos 
ganglionares  del  cuello  ni  estigmas  de  heredo  sifilis  y  la  reacci6n  de  Wasser- 
mann  fu6  negativa.  Desde  pequefia  tuvo  varies  ataques  de  conjuntivitis 
eczematosa,  permaneciendo  algunos  afios  libre  de  ellos;  pero  desde  hace  seis 
afios  ha  vuelto  a  tener  brotes  de  ella.  Hace  seis  meses  se  queja  de  tos.  Se  ha 
acentuado  su  enflaquecimiento  y  a  veces  por  las  tardes,  tiene  elevaciones  de 
temperatura  y  sudores  profusos.  El  padecimiento  que  la  ha  traido  a  consulta 
data  de  tres  meses,  encontrdndose  al  examen  del  ojo  izquierdo  una  con- 
juntivitis flictenular  de  forma  grave,  con  panus,  flictenas  en  la  cornea  y  dos 
ulceras  pequefias  de  hordes  netos  y  redondos,  como  hechas  con  sacabocado  y 
con  insignificante  infiltration  de  ellos  y  del  fondo.  La  fotofobia  era  tan  in- 
tensa,  que  la  enferma  ocultaba  su  cabeza  entre  el  colch6n  y  las  almohadas,  y 
habia  ademas  una  intensa  cefalea.  El  ojo  derecho  acusaba  en  la  cornea 
huellas  de  varios  ataques  del  padecimiento.  El  examen  general  de  la  enferma 
hizo  presumir  una  tuberculosis  pulmonar  incipiente.  El  von  Pirquet  fu6" 
debilmente  positivo. 

No  obstante  los  datos  anteriores  se  comenzo  a  inyectar  neosalvarsan  por  la 
via  endovenosa,  obtenie"ndose  una  curacion  tan  r^pida  que  a  los  tres  dias  de  la 
segunda  inyecci6n,  las  ulceras  estaban  espejeantes,  el  panus  muy  adelgazado  y 
la  fotofobia  y  la  cefalea  habian  desaparecido.  Despue"s  de  la  tercera  inyec- 
ci6n  fue"  necesario  suspender  el  tratamiento,  en  vista  de  la  dificultad  para 
puncionar  las  venas  a  la  paciente  y  este  descanso  determine  la  reaparici6n  de 
algunas  flictenas  y  un  pequefio  engrosamiento  del  panus.  En  vista  de  lo  cual 
le  fu4  aplicada  una  dosis  de  0.30  en  la  yugular,  haci&idose  sentir  mas  tarde  los 
efectos  bene'ficos.  La  enferma  euro  despue's  de  un  tratamiento  de  seis  inyec- 
ciones.  El  estado  general  mejor6  notablemente  y  desaparecieron  muchos  de 
los  sfntomas  que  hacfan  presumir  la  tuberculosis  pulmonar. 

DISCUSION 

Es  innegable  que  la  mayor  parte  de  las  conclusiones  relativas  a  la 
etiologfa  de  este  padecimiento,  convergen  hacia  la  hipotesis  de  su 
origen  tuberculoso,  y  digo  hipotesis  porque  hasta  la  fecha  no  se  ha 
senalado  la  presencia  del  bacilo  de  Koch  en  las  flictenas,  ni  tampoco  de 
una  manera  constante  en  el  organismo  de  los  enfermos.  Esta  uni- 
formidad  de  criterio  contrasta  desde  luego  con  la  accion  casi  nula  de 
toda  terape"utica  antituberculosa,  incluyendo  las  tuberculinas  y  con  los 
dos  hechos  fundamentales  que  antes  he  senalado:  su  frecuencia  en 
pacientes  sifiliticos  y  su  curacion  pronta  por  los  mercuriales  adminis- 
trados  ocal  y  generalmente,  asi  como  por  los  derivados  del  salvarsan. 


El  Tratamiento  de  las  Formas  Graves  de  Conjuntivitis         545 

El  problema  adquiere  una  complicacion  mayor  por  el  hecho  fre- 
cuentemente  observado  y  citado  por  algunos  autores  alemanes,  entre 
ellos  Zehener,  quienes  han  senalado  la  excesiva  coincidencia  de  la 
sifils  con  la  tuberculosis,  y  se  suponen  que  la  primera  de  estas  en- 
fermedades  prepara  favorablemente  el  terreno  debilitandolo,  para  que 
pueda  desarrollarse  con  mas  facilidad  la  segunda.  Ademas  han 
logrado  tratar  y  curar  por  un  tratamiento  antisifilitico  algunos  trastor- 
nos  que  indudablemente  no  eran  de  origen  tuberculoso.19 

De  los  datos  que  dejo  consignados,  asi  como  de  otros  muchos  que  no 
hubiera  sido  posible  relatar,  se  desprende  que  tanto  la  sifilis  como  la 
tuberculosis  pueden  estar  presentes  en  el  enf ermo,  solos  o  en  concurso ; 
pero  de  todas  maneras  el  problema  acerca  de  la  etiologia  del  padeci- 
miento  queda  en  pie,  pues  como  lo  he  indicado,  las  valiosas  pesquizas 
de  aptos  y  respetables  investigadores,  no  han  llegado  a  demostrar  en 
el  la  naturaleza  tuberculosa,  ni  menos  por  los  datos  que  llevo  con- 
signados debe  deducirse  un  origen  sifilitico. 

Sin  embargo,  la  hipotesis  de  que  en  un  gran  mimero  de  casos 
pueda  atribuirse  a  la  sifilis  el  padecimiento,  no  es  tan  despreciable. 
En  efecto,  desde  Iwanoff  quien  fue  el  primero  en  estudiar  la  anatemia 
patalogica  de  las  flictenas,  se  ha  comprobado  que  estas  lesiones  corre- 
sponden  a  inflamaciones  del  tipo  nodular  en  su  face  inicial,  lo  que  ha 
hecho  mirar  a  los  partidarios  del  origen  tuberculoso  un  pequeno 
tube"rculo  en  la  flictena;  pero  precisamente  esto  seria  lo  que  daria 
algun  fundamento  al  origen  sifilitico  de  la  lesion.  Realmente,  el  micro- 
scopic dificilmente  podria  decir  si  una  granulacion  pequena  y  reciente, 
supongamos  de  las  meninges,  seria  sifilitica  o  tuberculosa,  pues  ambas 
tiene  exactamente  la  misma  forma  de  infiltracion  linfocitaria,  forma- 
cion  de  celdillas  gigantes,  etc.,  y  solo  la  distincion  es  posible  cuando  el 
examen  se  lleva  sobre  lesiones  mas  avanzadas,  en  las  que  ya  es  posible 
observar  las  zonas  necroticas,  disminucion  de  la  irrigacion  sanguinea, 
etc.,  en  el  tuberculo;  o  bien  el  tejido  de  neoformaci6n,  esclerosis  y 
demas  caracteres,  que  identifican  las  lesiones  sifiliticas. 

Bien  pudiera  decirse  que  esta  hipotesis  va  tomando  forma,  pues  en 
los  casos  de  conjuntivitis  flictenular  de  duracion  muy  prolongada  y  en 
la  queratitis  fascicular,  algunos  autores,  entre  ellos  Gruber,  Hertel, 
Augstein,  Yamaguchi,  Baas,  etc.,  han  senalado  en  la  capa  de  Bowman 
y  aun  debajo  de  ella,  invadiendo  el  tejido  propio  de  la  cornea,  algunas 
esclerosis  y  producciones  de  tejido  de  nueva  formaci6n.  De  estos 
autores  el  ultimo  mencionado,  no  solo  ha  demostrado  estas  lesiones, 
35 


546  ANTONIO  TORRES  ESTRADA 

sino  que  eran  frecuentes  en  pacientes  sifiliticos  y  pudo  ademas  de- 
mostrar  en  los  ojos  exminados,  algunas  lesiones  de  coroiditis  sifilitica.20 

Estos  datos,  unidos  a  la  no  inoculabilidad  del  padecimiento ;  a  la 
ausencia  de  microrganismos  patogenos  en  las  lesiones,  por  mas  empefio 
que  ha  habido  en  descubiertos,  y  a  la  accion  curativa  que  tienen  los 
agentes  antisifiliticos,  robustecen  la  hipotesis  del  origen  sifilitico  de  la 
conjuntivitis  flictenular,  si  no  en  todos  los  casos,  por  lo  menos  en  una 
gran  parte. 

Carezco  por  completo  de  la  autoridad  y  de  los  fundamentos  nece- 
sarios  para  asentar  categoricamente  esta  aseveracion;  pero  quedaria 
altamente  honrado  y  satisfecho  si  con  lo  que  he  dicho  hasta  ahora 
abriera  nuevas  vias  de  investigacion,  fueran  o  no  coronadas  por  el 
e"xito. 

De  todas  maneras  estdn  patentes  las  conclusiones  que  hacen  pre- 
sumir  el  origen  tuberculoso  de  la  enfermedad  y  no  creo  que  sea  tan 
facil  destruirlas. 

En  cuanto  a  la  accion  curativa  de  los  mercuriales,  no  se  realmente  a 
que  atribuirla,  sobre  todo  en  ausencia  de  sifilis  en  el  enfermo.  Queda 
la  posibilidad  de  considerarles  propiedades  terapeuticas  distintas  de 
las  senladas. 

Mucho  se  ha  dicho  de  su  accion  resolutiva;  pero  esta  cada  dfa  pierde 
terreno  por  encerrar  una  idea  vaga,  muy  poco  satisfactoria,  si  no  es 
que  muchas  veces  erronea.21 

En  cuanto  a  los  derivados  del  salvarsan  hay  una  gran  tendencia  a 
emplearlos  en  diversidad  de  padecimientos  que  no  son  sifiliticos  ni 
hematoparasitarios,  tales  como  la  piorrea,  el  reumatismo,  la  oftalmia 
simpatica  (Morax22),  la  gangrena  pulmonar  (Svolin  y  Sjoblom23),etc. 
Pero  la  mayoria  de  los  autores  que  emplean  dichos  derivados  arseni- 
cales  en  los  padecimientos  no  sifiliticos,  no  indican  la  manera  como 
obran. 

Tratdndose  de  enfermos  sifiliticos  tampoco  es  facil  darse  cuenta 
exacta  de  la  manera  como  obran  los  agentes  terapeuticos,  mercurio  y 
salvarsan,  pues  no  habiendose  demostrado  la  naturaleza  sifilitica  del 
padecimiento,  no  se  puede  atribuir  a  esta  circunstancia  su  curacion. 

En  los  casos  en  que  la  sifilis  y  la  tuberculosis  concurren  en  el 
paciente,  la  explication  se  hace  mas  incomprensible  y  se  podria  sentar 
la  hipotesis  de  que  estos  casos  serian  mas  favorecidos  que  aquellos  en 
que  solo  existe  la  tuberculosis,  debido  a  que  los  agentes  especificos 
obrarf an  de  una  manera  ma's  segura,  robusteciendo  al  organismo ;  lo 
cual  se  podria  lograr  por  un  camino  indirecto,  o  sea  estimulando  al 


El  Tratamiento  de  las  Formas  Graves  de  Conjuntivitis         547 

organismo  por  una  medication  tonica,  mejorando  la  alimentation  y  las 
condiciones  higienicas. 

CONCLUSIONES 

1.  Los  casos  graves  de  conjuntivitis  eczematosa  constituyen  aun  un 
problema  muy  serio  para  el  oftalmologo  y  una  amenaza  para  la  vista 
de  los  ninos  quienes  son  los  que  habitualmente  padecen  esta  en- 
fermedad. 

2.  La  etiologia  del  padecimiento  por  ahora  es  completamente 
desconocida.    Generalmente  se  atribuye  a  las  toxinas  tuberculosas ; 
pero  no  es  esta  la  linica  causa. 

3.  La  sifilis  es  frecuente  en  los  ninos  afectados  de  la  enfermedad, 
hecho  que  casi  no  ha  sido  mencionado;    pero  no  hay  fundamentos 
suficientes  para  atribuir  el  padecimiento  ocular  a  dicha  enfermedad. 

4.  El  mercurio  y  los  derivados  del  salvarsan,  tienen  una  action 
marcadamente  especifica  contra  el  padecimiento. 

BIBLIOGRAFIA 

1.  Colombo:    Klin.  Monatsbl.  f.  Augen.,  1,  p.  2,  p.  610,  1912;  citado  por  the 

American  Encyclopedia  of  Ophthalmology,  ix,  6801. 

2.  H.  H.  Turner:    Etiology  of  Phlyctenular  Ophthalmia,  American  Journarof 

Ophthalmology,  ii,  No.  2,  1919,  115. 

3.  Terrien:    Cit.  por  la  Revista  Cubana  de  Oftalmologia,  ii,  No.  3,  1920,  604. 

4.  Wolff,  C.  K. :  Relapsing  Phlyctenular  Keratitis  in  Children,  Lancet,  mayo  de 

1920, 509.    Cit.  por  The  Ophthalmic  Literature,  xvii,  No.  1,  98. 

5.  Gibson:   Revista  Cubana  de  Oftalmologia,  No.  3, 1919,  377. 

6.  Weckers:    The  American  Encyclopedia  of  Ophthalmology,  ix,  6802. 

7.  Wesseley:    Munch,  med.  Woch.,  1920,  cit.  por  The  Ophthalmic  Literature, 

xvii,  87,  mayo  de  1921. 

8.  Kollner:    Ocular  Eczema  and  Skin  Tuberculosis  (Munch,  med.  Woch.,lxvi, 

1919, 1109),  cit.  Por  The  Ophthalmic  Literature,  xvii,  88. 

9.  J.  C.  Fernandez  MacGregor:     La  querato  conjuntivitis   eczematosa,   tesis 

professional,  p.  10. 

10.  Pacheco  Luna:    Revista  Cubana  de  Oftalmologia,  ii,  226. 

11.  Burnett:    American  Encyclopedia  of  Ophthalmology,  ix,  6801. 

12.  V.  Morax:    Precis  d'Ophtalmologie,  deuxieme  edition,  p.  196. 

13.  Daniel  M.  Velez:   Acci6n  de  la  tuberculina  en  los  ojos  sanos  y  enfermos, 

Anales  de  la  Sociedad  Mexicana  de  Oftalmologia  y  Otorinolaringologia, 
ii,  No.  12,  240. 

14.  Pacheco  Luna:    Revista  Cubana  de  Oftalmologia,  ii,  225. 

15.  Andrade:    Revista  Cubana  de  Oftalmologia,  iii,  231. 

16.  L.  D.  Wecker  y  Landolt:    Trite  Complet  d'Ophtalmologie,  i,  345. 

17.  Wolff:    Revista  Cubana  de  Oftalmologia,  i,  No.  4,  1919. 

18.  Bruns:    The  American  Encyclopedia  of  Ophthalmology,  ix,  6803. 


548  ARNOLD  RENSHAW 

19.  K.  Zehner:  Schweizerische  medizinische  Wochenschrift,  1920,  No.  30,651. 

Cit.  por  The  American  Journal  of  Syphilis,  v,  No.  1,  151. 

20.  Baas:    Pathology  of  the  Eyes.  Parsons,  cit.  por  The  American  Encyclopedia 

of  Ophthalmology,  ix,  6799. 

21.  Torres  Estrada:  La  Sifilis  como  factor  en  algunas  complicaciones  del  tifo  y  de 

la  influenza,  Anales  de  la  Sociedad  de  Oftalmologia  y  Otorinolaringologia, 
ii,  2,  epoca,  No.  10,  227. 

22.  Morax:    Cit.  por  el  Dr.  Arruga.  Tratamiento  de  la  Of talmia  simpatica  por  el 

salvarsan  y  sus  derivados,  Espafia  Oftalmol6gica,  Ano  v,  No.  3. 

23.  M.  Svolin  y  J.  C.  Sjoblom:  La  neoarsfenamina  en  el  tratamiento  de  la  gang- 

rena  pulmonar,  Del  Finska  Lakaresallskapets  Handlingar,  Helsingfors, 
Julio  de  1921.  Cit.  por  the  Journal  American  Medical  Association,  E.  E., 
vi,  No.  10,  717. 


THE  EFFECTS  OF  DIRECT  INSTILLATION  OF  NOV- 
ARSENOBILLON  IN  THE  CONJUNCTIVAL  SAC  IN 
RESISTANT  CASES  OF  CONGENITAL  SYPHILITIC 
INTERSTITIAL  KERATITIS 

ARNOLD  RENSHAW,  M.D.,  B.S.  (Lond.),  D.P.H.  (Mane,  and  Cantab.) 
Hon.  Pathologist,  Ancoats  Hospital,  and  Bacteriologist,  Royal  Eye  Hospital, 

Manchester 

Manchester,  England 

In  any  extensive  series  of  cases  of  interstitial  keratitis  of  syphilitic 
origin  one  comes  across  a  number  which  are  very  resistant  to  ordi- 
nary mecurial  treatment.  At  the  Royal  Eye  Hospital  in  Manchester 
these  cases,  and  in  fact  most  of  the  ordinary  type,  are  submitted  to 
treatment  by  means  of  salvarsan  or  its  derivatives,  novarsenobillon, 
neosalvarsan,  or  neokharsivan.  Of  these  I  have  been  able  to  dis- 
tinguish three  types: 

1.  The  type  which  rapidly  improves  under  combined  mercurial  and 
arsenical  treatment. 

2.  The  type  which  rapidly  improves  but  subsequently  relapses 
under  this  treatment. 

3.  The  type  which,  even  after  prolonged  administration  of  mercury, 
iodids  and  salvarsan  derivatives  fails  to  improve  in  so  far  as  the  in- 
filtration of  the  cornea  is  concerned.     Having  noted  that  a  definite 
ground-glass  or  hazy  appearance  of  the  cornea  persisted  even  after 
twelve  to  fifteen  injections  of  novarsenobillon  or  neokharsivan,  it 


Novarsenobillon  in  Congenital  Syphilitic  Interstitial  Keratitis    549 

occurred  to  me  that  the  direct  instillation  of  concentrated  solutions  of 
the  novarsenobillon  might  be  of  use.  In  view,  however,  of  the 
irritant  action  of  this  drug  on  the  subcutaneous  tissues,  I  discussed 
the  matter  with  Dr.  J.  Gray  Clegg,  of  the  Manchester  Royal  Eye 
Hospital,  and  we  decided  that  it  was  advisable  to  ascertain  the  effects 
on  the  eyes  of  animals  before  using  it  clinically  on  human  beings. 
A  1%  solution  of  N.  A.  B.  in  distilled  water  was  prepared  and  instilled 
into  the  conjunctival  sacs  of  the  eyes  of  rabbits.  The  results  were 
examined  by  Dr.  Clegg  and  myself,  and  he  decided  that  there  appeared 
to  be  nothing  to  contraindicate  its  use  in  children.  Accordingly  a 
number  of  patients  were  submitted  to  me  by  him  for  this  method  of 
local  treatment. 

Subsequently  other  members  of  the  honorary  staff  of  the  Man- 
chester Royal  Eye  Hospital  sent  cases  for  similar  applications.  All 
the  above-mentioned  types  have  been  dealt  with;  namely,  the  early 
type,  the  relapsing  type,  and  the  resistant  type.  In  the  two  former 
types  general  anti-syphilitic  treatment  was  in  its  earlier  stage  and  it 
is  difficult  to  appraise  in  a  scientific  manner  the  exact  value  of  the 
local  treatment  with  regard  to  the  improvement  found. 

Its  effect  was  more  to  be  noticed,  therefore,  in  the  resistant  type 
which  had  been  treated  so  thoroughly  with  mercury,  iodids,  and 
salvarsan  derivatives  that  one  became  almost  hopeless  of  any  further 
good  resulting.  Instillations  have  been  continued  over  a  period  of 
months  from  the  cessation  of  general  treatment  by  salvarsan  deriva- 
tives. 

METHOD. — A  few  drops  of  a  1%  solution  of  novarsenobillon  deriva- 
tives in  distilled  water  were  dropped  into  the  eyes  usually  at  intervals 
of  seven  days,  but  in  the  later  stage  the  interval  has  been  fourteen 
days.  The  total  number  of  cases  treated  was  20. 

The  immediate  effect  of  instillation  is  a  slight  hyperemia  at  the 
corneal  limbus.  The  patients  usually  complain  only  of  slight  irrita- 
tion, but  the  lacrimal  secretion  is  increased  temporarily. 

The  patient  is  recumbent  during  the  application,  and  is  told  to  roll 
the  eyeball  about  so  as  to  get  a  uniform  concentration  of  the  drug, 
and  the  drops  are  added  slowly,  preferably  until  the  dilatation  of  the 
circumcorneal  vessels  is  well  marked.  The  effects  consist  chiefly  of 
some  slight  alleviation  of  the  photophobia  in  the  earlier  cases,  manifest 
after  two  or  three  weeks.  Secondly,  in  the  more  resistant  cases,  in 
which  intravenous  injections  have  been  abandoned,  the  corneal  haze 


550  ARNOLD  RENSHAW 

gradually  disappears  and  the  substantia  propria  becomes  compara- 
tively clear.  The  cornea  resumes  its  transparency  first  at  the  periph- 
ery, and  usually  the  upper  part  of  the  cornea  clears  before  the 
lower  part.  The  disappearance  of  the  corneal  infiltration  is,  of  course, 
associated  with  much  improved  vision,  and  one  patient  under  this 
form  of  treatment  can  now  thread  with  ease  a  very  fine  needle  whereas 
previously  she  could  scarcely  detect  hand  movements.  The  effect  in 
all  cases  has  been  to  reduce  the  degree  of  corneal  infiltration;  and  in 
relapsing  cases  to  subdue  the  local  inflammation. 

ILL  EFFECTS. — So  far  as  can  be  ascertained  no  ill  effects  are  pro- 
duced. In  one  case  only,  a  very  difficult  one,  which  had  resisted  all 
forms  of  treatment,  a  slight  corneal  ulcer  formed  and  perforation 
occurred,  but  this  might  have  happened  quite  apart  from  this  form  of 
treatment,  and  the  patient  made  a  good  recovery,  the  cornea  eventu- 
ally clearing  very  well  except  for  a  small  scar  of  the  ulcer  at  the  per- 
foration site. 

CONCLUSION. — This  method  is,  I  believe,  a  very  valuable  adjunct 
to  the  usual  treatment ;  further,  this  method  can  be  continued  when 
further  intravenous  injections  become  dangerous. 

It  should,  however,  be  used  only  as  an  adjunct  to  general  systematic 
treatment  of  the  disease. 

It  is  interesting  to  speculate  as  to  whether  Spirochsetse  are  actually 
present  in  the  cornea,  and  if  so  whether  their  persistence  is  due  to  the 
lack  of  blood  supply  to  this  tissue. 

I  wish  to  express  my  indebtedness  to  the  courtesy  of  Dr.  Clegg,  who 
has  specially  assisted  in  this  investigation  and  to  the  other  members 
of  the  honorary  staff  who  have  also  submitted  their  cases  for  this 
treatment. 


TRATAMIENTOS  DE  LAS  QUERATITIS  INFECCIOSAS 
FOR  LAS  VACUNAS 

DOCTOR  ROVIROSA  VIRGILI 

Madrid,  Espana 

LA  BACTERIOTERAPIA  EN  OFTALMOLOGIA 

Voy  a  tratar  de  un  asunto  completamente  nueva  en  el  terreno  de  la 
oftalmologia,  y  de  tal  importancia,  que  creo,  andando  el  tiempo,  ha 
de  constituir  un  verdadero  tesoro  para  dicha  especialidad. 

El  progreso  que  realiza  la  vacuna  estafilococica,  y  alcanza  de  dla 
en  dia  en  el  campo  medico  quinirgico,  no  podia  por  menos  de  llamarme 
la  atencion  y  por  ende  ensayar  un  agente  terapeutico  que  nos  podia 
reportar  ya  como  curative,  ya  como  coadyuvante,  inmensos  bene- 
ficios  en  la  practica  de  la  oftalmologia. 

Todos  sabemos  los  medios  para  combatir  localmente  los  estragos 
causados  por  el  estafilococo  piogeno  en  el  organo  de  la  vision;  pero 
todos  tampoco  desconocemos  la  insuficiencia  de  estos  medios  en 
multiples  y  determinados  casos,  como  en  panoftalmias,  queratitis 
ulcerosas,  dacriocistitis,  blefaritis  ulcerosas,  etc.,  que  6  bien  se  hace 
en  unos  casos  necesaria  la  extirpacion  del  organo,  y  en  otros,  a  pesar 
de  los  mejores  medios  empleados  y  la  mayor  constancia,  se  retarda  la 
curacion  de  un  modo  indefinido. 

Sabemos  que  la  experimentacion  clinica  no  ha  demostrado  todavfa 
en  las  afecciones  oculares  la  eficacia  curativa  de  los  sueros  estafilo- 
cocico  y  estreptococico  (inmunizacion  pasiva). 

Por  lo  tanto  un  agente  como  la  vacuna  estafilococica  polivalente 
(inmunizacion  activa),  es  decir,  que  obra  excitando  al  organismo  a  la 
produccion  de  anticuerpos  en  la  totalidad  del  individuo,  y  al  mismo 
tiempo  que  libran  al  organismo  de  lo  que  por  la  puncion  artificialmente 
le  hemos  introducido,  llegan  al  proceso  estafilococico  ocular  y  contri- 
buyen  a  su  curacion,  ha  de  ser,  andando  el  tiempo  y  cuanto  mds  se 
hay  a  estudiado,  jalon  inestimable  para  la  especialidad  oftalmologica. 

Los  primeros  vacunados  fueron  dos  enfermos  de  panoftalmia,  y 
como  por  su  historia  clinica  se  vera,  en  los  dos  se  ha  podido  evitar  la 
enucleacion;  mas  en  la  mujer  la  reparacion  tomo  tal  incremento,  que 

551 


552  ROVIROSA  VIRGILI 

fu6  aclardndose  la  cornea  de  tal  manera,  que  ha  llegado  a  distinguir 
visi6n  de  bultos;  venfa  propuesta  para  enucleacion  de  otra  clfnica, 
presentando  fenomenos  tan  alarmantes,  que  yo  tambien  de  no  haber 
podido  disponer  de  la  vacuna,  me  hubiera  visto  precisado  a  recurrir 
al  extreme  antes  dicho  a  fin  de  evitar  la  oftalmfa  simpatica. 

El  tercer  -caso  tratado  con  vacuna  es  un  niiio,  a  quien  solo  incindi 
el  saco  lagrimal,  raspando  profundamente  sus  paredes,  pero  conser- 
vando  el  organo,  habiendo  antes  hecho  una  siembra  en  agar,  y  de  la 
que  se  obtuvo  una  auto-vacuna.  A  la  cuarta  inyecci6n  habia  des- 
aparecido  el  pus  completamente,  cicatrrzando  a  los  pocos  dfas. 

El  examen  bacteriologico  llevado  a  cabo  por  el  Dr.  Mayoral  dio 
un  bacilo  del  grupo  del  dipte"rico,  y  que  ha  encontrado  muchas  veces 
en  inflamaciones  cronicas  diversas,  y  sobre  todo,  en  otitis  y  rinitis. 

Los  otros  dos  casos  de  raspados  que  corresponden  al  16  y  18,  en 
los  que  se  emplean  la  auto-vacuna  y  vacuna  estafilococica,  respectiva- 
mente,  ambos  cicatrizan  rapidamente  a  los  veintiuno  y  diez  y  nueve 
dfas  de  la  aplicacion  de  la  vacuna. 

En  los  demds  casos  ha  sido  la  vacuna  un  poderoso  coadyuvante, 
pues  vemos  se  ha  modificado  muy  satisfactoriamente  la  supuracion,  y 
en  algunos  casos  por  completo  hasta  el  presente. 

Por  la  rapidez  con  que  se  ha  presentado  la  cicatrizacion  en  los  tres 
casos  de  intervencion,  creo  sera  un  medio  terape*utico  no  despreciable 
en  las  afecciones  de  las  vias  lagrimales,  estando  el  beneficioso  papel 
encomendado  y  digno  de  estudiarse  a  las  auto-vacunas. 

Cuarto  caso.  La  enferma  presenta  dos  ulceras,  una  que  ocupa 
toda  la  parte  supero-externa  de  la  cornea,  y  otra  la  infero-externa  de  la 
misma,  habiendo  entre  sus  bordes  una  distancia  minima  de  dos  mfli- 
metros  por  la  parte  central.  La  flogosis  conjuntival  es  intensa,  los 
dolores  agudos  y  glerosis  de  la  conjuntiva;  a  todo  esto,  como  la 
enferma  habia  perdido  hace  afios  el  ojo  conge*nere,  por  ulceras  seme- 
j  antes  a  las  presentes,  el  estado  de  abatimiento  es  enorme.  Hecha  la 
siembra  en  agar,  encuentra  el  Dr.  Mayoral  el  estafilococo  pi6geno. 

Despues  de  la  primera  inyeccion,  al  dfa  siguiente,  hay  un  pequeno 
aumento  de  la  flogosis  y  pus,  por  lo  que  la  Ifnea  demarcativa  de  las 
ulceraciones  avanza  algo ;  avanzamiento  muy  compensado  al  otro  dfa 
por  la  remision,  no  s61o  de  los  bordes  ulcerados,  sino  de  los  trastornos 
subsiguientes  a  esta  clase  de  queratitis,  cesando  tambie'n  el  estado  de 
aplanamiento  en  que  se  hallaba  la  enferma,  y  se  le  prdctica,  con  dos 
dfas  de  intervale,  una  segunda  inyeccion  estafilococica  polivalente. 
Solo  se  ha  podido  apreciar  dos  de"cimas  de  aumento  en  la  temperatura, 


Tratamientos  de  las  Queratitis  Infecciosas  por  las  Vacunas     553 

y  las  queratitis  marchan  francamente  en  la  curacion.  Solo  se  emplean 
en  dias  sucesivos  dos  inyecciones  mas  hasta  la  curacion  defmitiva. 

Como  huellas  del  proceso  antes  dicho,  se  aprecian  en  la  cornea  dos 
cicatrices  sumamente  tenues,  y  como  se  ha  podido  evitar  la  fusion  de 
sus  bordes  por  la  parte  central,  la  enferma  queda  con  la  vision  perfecta. 

Los  casos  16°  y  18°  corresponden  a  una  queratitis  ulcerosa  con 
hernia  y  a  una  queratitis  perforante  con  hipopion,  respectivamente ; 
en  ambos  enfermos  se  ha  inyectado  la  vacuna  estafilococica  poli- 
valente,  y  ambos  han  seguido  identicas  fases  que  el  caso  primero 
expuesto,  quedando  la  hernia  reducida  en  el  primero  y  cicatrizada  la 
fistula  corneal  en  el  segundo. 

Los  tres  casos  de  queratitis  ulcerosa  que  he  citado,  como  ven  los 
lectores,  son  de  lo  m&s  grave;  y  si  bien  se  han  tratado,  como  ya  se 
supone,  localmente,  tambien  he  de  advertir  que  estos  medios  fra- 
casaron  hasta  que  se  aplico  la  vacuna  estafilococica. 

El  ultimo  caso  de  lilcera  serpiginosa  de  la  cornea  con  hipopion,  que 
ocupaba  la  tercera  parte  de  la  cdmara  anterior,  rasando  con  la  exca- 
vacion  ulcerosa,  ha  sido  tratado  por  la  vacuna  pneumococica  del 
Laboratorio  Municipal  de  Madrid. 

Al  dia  siguiente  de  la  primera  inyecci6n  acusa  el  enfermo  haber 
sufrido  durante  la  noche  un  fuerte  dolor,  como  un  latigazo.  A  la 
inspecci6n  macrosc6pica  se  observa  una  gran  remision  del  hipopion, 
el  iris  un  poco  sanguinolento  y  cierto  rezumamiento  de  pus  que, 
despue"s  de  limpiado,  deja  ver  una  fistula  en  el  centre  de  la  lilcera,  es 
decir  que  se  trata  de  una  paracentesis  espontanea  de  la  camara  an- 
terior. 

Al  tercer  dia  el  hipopion,  muy  reducido,  apenas  se  distingue  en  la 
parte  inferior  del  angulo  corneal;  al  cuarto  dia,  nueva  inyeccion  de 
vacuna  pneumoc6cica;  al  quinto  dia  ha  desaparecido  por  complete 
el  hipopion  y  la  ulcera  ha  entrado  en  vias  de  franca  cicatrizacion. 

De  no  haberse  verificado  la  paracentesis  espontdnea,  claro  estd 
que  toda  la  gloria  recaeria  en  la  vacuna  pneumococica;  pero  como  es 
bastante  frecuente  la  termination  favorable  de  estos  procesos  por 
hechos  an&logos,  ya  de  paracentesis  natural  6  provocada  con  el 
cuchillete  lanceolar  6  con  un  simple  midridtico,  este  hecho  puedo  restar 
algo  de  certidumbre,  aunque  la  marcha  ulterior,  regresion  rdpida  de 
todos  los  sintomas,  la  coloration  del  iris  que  recupera  pronto  su  bril- 
lantez  y  la  transparencia  pupilar  que  se  observa  a  los  pocos  dias, 
hacen  pensar  que  la  vacuna  no  ha  sido  un  factor  despreciable  en  el 
presente  caso. 


554  ROVIROSA  VIRGILI 

Los  cinco  casos  de  blefaritis  ciliar  que  a  continuation  expongo  todos 
datan  de  muchos  anos  de  duration,  y  en  algunos  se  remonta  su  eo- 
mienzo  a  la  edad  infantil.  En  todos  se  ha  comprobado  los  bene- 
ficiosos  resultados  de  la  vacuna  estafilococica  desde  las  primeras 
inyecciones,  y  hasta  el  caso  8°,  el  mds  rebelde,  y  de  smtomas  mas 
alarmantes,  en  cuya  siembra  se  hallo  el  streptococo,  cedio  a  la  auto- 
vacuna. 

CASOS 

1.  Rafael  Lopez,  veintisiete  anos,  natural  de  Mostoles.    Carretera  de 
Getafe.    Ingreso  el  8  de  Enero  de  1915. 

Diagnostico:  Ulcera  infiltrada  de  toda  la  cornea  ojo  izquierdo,  con  smto- 
mas de  panoftalmia. 

Terapeutica:  Se  le  aplica  la  vacuna  estafiloc6cica  en  los  dias  11, 14, 17  y  20, 
y  se  le  da  de  alta  el  31  del  mismo  mes. 

Observaciones :  A  travel  del  leu  coma  se  percibe  la  coloration  del  iris;  la 
temperatura  no  se  ha  elevado  mds  que  3  decimas  a  la  primera  inyeccion. 

2.  Catalina  Roncero  Diaz,  cuarenta  y  nueve  anos,  natural  de  Toledo. 
Sombrereria,  5.    Ingreso  el  14  de  Enero  de  1915. 

Diagnostico:  Panoftalmia  ojo  izquierdo,  propuesta  ya  para  enucleacion  en 
otra  clinica.  La  primera  vacuna  se  efectua  el  dia  de  su  entrada;  el  17  se  le 
aplica  la  segunda,  y  dos  mas  en  los  dias  20  y  23. 

Observaciones:  Desde  la  segunda  vacuna  cesan  los  dolores  y  se  despeja 
la  cornea  por  su  parte  superior;  al  terminar  la  cuarta,  solo  presenta  leucoma 
la  mitad  inferior  corneal. 

3.  Jos6  Maria  Vegas  Perez,  doce  anos,  natural  de  Madrid.    Pez,  1  prin- 
cipal. 

Diagnostico:  Dacrio-cistitis  ojo  izquierdo;  raspado  prof  undo  del  saco 
lagrimal;  a  pesar  de  ello,  hay  alguna  supuracion,  que  desaparece  a  la  tercera 
inyeccion  de  vacuna  autogena,  cicatrizando  completamente  despues  de  la 
cuarta  inyecci6n. 

4.  Ana  Maria  Pizarro,  sesenta  anos,  natural  de  Puertollano.    Ingreso  el 
17  de  Febrero  de  1915. 

Diagnostico:  Queratitis  ulcerosas  ojo  derecho.  Se  le  aplica  la  vacuna 
estafilococica  en  los  dias  21,  24  y  28  de  Febrero  y  4  y  8  de  Marzo,  dandosele  el 
alta  el  25  del  mismo  mes. 

5.  Priscila  Perez,  diez  anos,  natural  de  Villanueva  del  Campillo.     Ingresa 
el  20  de  Febrero  de  1915. 

Diagnostico:  Blefaro-conjuntivitis  cronica  de  muchos  anos,  a  pesar  de  los 
tratamientos  corrientes  en  esos  casos,  no  se  nota  mejorfa  hasta  la  a  plication 
de  la  primera  vacuna  estafilococica,  el  12  de  Marzo,  aplicandola  sucesivamente 
los  dias  16,  20,  25  y  31  del  mismo  mes. 

Observaciones:    En  lugar  de  los  hordes  ciliares,  rojos  y  desprovistos  de 


Tratamientos  de  las  Queratitis  Infecciosas  por  las  Vacunas     555 

pestana  que  presentaba  la  enferma  a  su  ingreso  en  mi  clinica,  presentan  en 
la  actualidad  su  coloration  normal,  empezando  a  contarse  algunas  pestanas. 

6.  Benigno  Galan,  treinta  y  ocho  aftos,  natural  de  Madrid.     Miraelsol, 
no.  4.     Entr6  el  8  de  Marzo  de  1915. 

Diagnostico:  Blefaro-conjuntivitis  antigua,  desde  que  era  nifto.  Se  le 
aplica  la  vacuna  estafilococica  en  los  dias  12,  16,  20,  26  y  31  de  marzo  y  8  de 
Abril,  habiendo  mejorado  notablemente. 

7.  Hermenegilda  die  Barrio,  treinta  y  siete  aiios,  natural  de  Segovia. 
San  Vicente,  38.     Entro  el  20  de  Diciembre  de  1914. 

Diagnostico:  Dacrio-cistitis  ojo  izquierdo;  se  la  trata  con  sondas  e"  irri- 
gaciones  desinfectantes,  a  pesar  de  lo  cual  no  cesa  del  todo  la  supuracioH. 
Se  le  inyecta  la  primera  vacuna  estafilococica  el  12  de  Marzo  de  1915,  y  se  le 
vuelve  aplicar  en  los  dias  16,  24  y  31  del  mismo.  En  la  actualidad  ha  cesado 
la  supuraci6n;  solo  hay  excretion  del  liquido  mucoso. 

8.  Mercedes  Iglesias  Taboada,  treinta  y  un  aftos,  natural  de  Toledo  Divino 
Pastor,  1. 

Diagnostico:  Blefaro-conjuntivitis  cronica  de  muchos  afios,  pe"rdida  abso- 
luta  de  las  pestanas  y  escoriaciones  que,  naciendo  del  borde  ciliar  se  extienden 
por  la  epidermis  palpebral.  Se  le  aplica  la  vacuna  estafilococica  en  los  dias 
13,  17,  20,  24  y  31  de  Marzo,  habiendose  modificado  bastante,  pero  no  lo 
debido,  por  lo  cual  se  le  hace  una  vacuna  autogena  en  la  que  se  halla  el  estrep- 
tococo,  y  con  cuya  aplicacion  se  logra  el  resultado  apetecido. 

9.  Francisca  Recio  Guerra,  veinticuatro  anos,  natural  de  Santa  Cruz  del 
Retamar.     Corredera  Baja,  5. 

Diagnostico:  Blefaro-conjuntivitis  ulcerosa,  habiendo  sido  ya  operada  con 
exito  de  triquiasis;  los  bordes  escoriados  y  sin  pestanas;  se  le  aplica  la  vacuna 
estafilococica  en  los  dias  13,  16,  20  y  31  de  Marzo,  y  3  y  6  de  Abril;  en  el  pre- 
sente  se  observa  una  coloraci6n  normal  en  los  bordes  ciliares,  y  acusa  la  en- 
ferma una  comodidad  nunca  sentida. 

10.  Amalio  Quiroga,  18  anos,  natural  de  Villanueva  de  la  Torre.     Luisa 
Fernanda,  14. 

Diagnostico:  Blefaro-conjuntivitis  eczematosa,  presentando  un  eczema 
muy  extenso  en  las  cejas  y  la  f rente,  que  ha  resistido  a  cuantos  tratamientos 
se  han  ensayado  en  el.  Se  le  aplica  la  vacuna  estafilococica  en  los  dias  13, 
16,  20,  24,  y  31  de  Marzo,  habiendo  desaparecido,  no  s6lo  el  eczema  ciliar, 
sino  tambi£n  el  frontal. 

11.  Jose  Zamora  Mendez,  natural  de  Madrid,  Buenavista,  35. 
Diagnostico:  Dacri-cistitis  doble:  a  pesar  de  haberse  empleado  las  sondas 

de  mayor  calibre  e  irrigaciones  desinfectantes,  no  cesa  la  supuraci6n.  Se  le 
aplica  la  vacuna  estafilococica  en  los  dias  13,  16,  23  y  31  de  Marzo,  y  3  de 
Abril,  habiendo  desaparecido  completamente  el  pus  del  ojo  derecho  y  siendo 
necesario  el  empleo  de  una  auto-vacuna  para  conseguir  la  extincion  del  pus 
del  ojo  izquierdo. 


556  ROVIROSA  VIRGILI 

12.  Benita  Gonzalez,  treinta  y  siete  anos,  natural  de  Fuencarral.     Ingreso 
el  24  de  Febrero  de  1915. 

Diagn6stico:  Dacrio-cistitis  doble;  tratamiento:  sondas  e"  irrigaciones 
antise"pticas;  a  pesar  de  ello,  el  pus  no  desaparece.  Se  le  aplica  la  vacuna 
estafiloc6cica  en  los  dias  14,  18,  22  y  26  de  Marzo,  habiendo  desaparecido  el 
pus  hasta  el  presente. 

13.  Ram6n  Herranz,  cincuenta  y  cinco  anos,  natural  de  Moralejo.     (Sego- 
via).    San  J6se",  2. 

Diagn6stico:  Dacrio-cistitis  ojo  derecho;  a  pesar  de  sondarsele  mucho 
tiempo,  no  desaparece  el  pus.  Se  le  aplica  la  vacuna  estafiloc6cica  poli- 
valente  en  los  dias  14,  20,  25  y  30  de  Marzo;  en  le  presente  ha  cesado  la 
supuraci6n. 

14.  Hip6lita  Vidal,  treinta  y  dos  anos,  natural  de  Recas  (Toledo).     Plaza 
de  Salmeron,  4. 

Diagnostico:  Dacrio-cistitis  doble;  la  enferma  se  niega  tan  to  a  las  sondas 
como  a  la  operaci6n.  Se  le  aplica  la  vacuna  estafilococica  en  los  dias  15,  18, 
24  y  30  de  Marzo  y  8  de  Abril,  habiendo  cesado  la  supuracion  pero  conser- 
vando  cierta  rubicundez  y  mucosidad  que,  dada  la  naturaleza  de  la  enfer- 
medad  y  el  poco  tiempo  de  tratamiento,  no  permiten  emitir  un  juicio  satis- 
factorio  y  definitive. 

15.  Rosalia  Pastrana  Torre,  veintid6s  anos,  natural  de  Madriedejos. 
Diagn6stico:   Ulcera  perforante  de  la  cornea,  con  enturbiamiento  de  toda 

ella,  glerosis  conjuntival  y  fuertes  dolores;  en  vista  del  incremento  que  iba 
tomando  la  supuracion,  a  pesar  de  los  multiples  lavados  antise"pticos,  se  le 
aplica  la  vacuna  estafilococica  polivalente  en  los  dias  22,  25,  y  30  de  Marzo, 
y  3  y  9  de  Abril.  La  enferma  es  dada  de  alta  el  14  de  Abril,  con  una  cicatriz 
apenas  perceptible  y  una  buena  vision. 

16.  Agapita  Palafox,  treinta  y  dos  anos.     Guadalajara. 
Diagn6stico:  Dacrio-cistitis,  ojo  izquierdo,  en  el  que  se  le  prdctica  un  pro- 

fundo  raspado;  y  como  continua  la  supuracion,  se  hace  una  siembra  en  la 
que  se  halla  el  estafilococo,  del  que  se  obtiene  una  autovacuna  que  se  le  aplica 
el  27  y  31  de  Marzo  y  4  y  11  de  Abril,  habiendose  extinguido  por  complete  la 
supuracion,  con  conservation  del  organo  y  de  su  funcion. 

17.  Nominando  Lopez  Villar,  cincuenta  y  tres  anos,  natural  de  Juncos 
(Toledo). 

Diagn6stico:  Ulcera  herniada  con  hipopion.  Se  le  aplica  la  vacuna  esta- 
filococica el  31  de  Marzo  y  3  y  6  de  Abril;  se  ha  podido  reducir  la  hernia,  y 
habiendo  cicatrizado  completamente  ha  recuperado  una  buena  vision. 

18.  Gin£s  Monllor  Domenech,  treinta  y  nueve  anos,  natural  de  Madrid. 
Plaza  del  Rastro,  9. 

Diagn6stico:  Dacrio-cistitis  ojo  izquierdo;  raspado  del  saco  lagrimal. 
Como  hay  supuraci6n,  se  le  aplica  la  vacuna  estafilococica  en  los  dias  5,  10, 


Tratamientos  de  las  Queratitis  Infecciosas  por  las  Vacunas     557 

13,  y  16  de  Abril.  A  los  pocos  dias  de  la  primera  inyecci6n  desapareci6  el 
pus  y  la  cicatrizaci6n  se  presenta  franca. 

19.  Cirilo  de  la  Torre,  cincuenta  anos,  natural  de  Valdearenas.  (Gua- 
dalajara.) 

Diagn6stico:  Ulcera  serpiginosa,  con  grande  hipopi6n,  en  el  ojo  derecho; 
se  le  aplica  la  vacuna  pneumococica  en  los  dias  9,  12,  y  15  de  Abril.  Al  dfa 
siguiente,  a  la  primera  inyeccion,  sobreviene  una  paracentesis  espontdnea; 
iris  sanguinolento  y  cesaci6n  de  dolores;  en  las  inyecciones  siguientes  desa- 
parece  por  completo  el  hipopi6n;  la  pupila  se  presenta  completamente  negra 
y  redonde;  hay  una  excelente  visi6n. 

MARCHA 

En  las  enfermedades  cronicas,  como  dacrio-cistitis,  eczemas  pal- 
pebral  blefaritis  ciliar,  etc.,  puede  empezarse  con  dosis  de  0.50,  1.00  y 
1.50  de  vacuna  estafilococica  polivalente,  siendo  en  las  autovacunas 
la  mitad  de  las  dosis  antedichas,  siempre  teniendo  en  cuenta  el  peso 
del  individuo  y  en  las  afecciones  agud-as,  oftalmias  y  queratitis 
ulcerosas,  a  pesar  de  que  hay  que  tener  en  cuenta  la  fase  negativa, 
nosotros  hemos  empleado  las  mismas  dosis  elevadas,  sin  que  la 
pequena  agravacion  de  trastornos  locales  que  se  nota  en  esta  haya 
sido  de  gran  duracion;  en  los  presentes  casos  nunca  ha  llegado  a  las 
treinta  horas;  y  en  ciianto  a  los  fenomenos  generales,  solo  hemos 
podido  apreciar  unas  decimas  de  elevacion  de  la  temperatura. 

Si  esta  fase  negativa  resulta  algo  intensa,  hay  que  retardar  algo  ma's 
la  segunda  puncion  y  no  aumentar  ma's  la  dosis  anterior. 

RESUMEN 

Cinco  blefaritis  ciliares  de  las  mas  rebeldes  y  antiguas,  curadas. 

Se  ha  empleado  la  vacuna  estafilococica  y  streptococica  autogena. 

Tres  casos  de  raspado  de  saco  lagrimal  con  conservation  de  organo 
y  funcion. 

En  los  demas  tratados  por  el  sondaje  se  ha  extinguido  el  pus  hasta  el 
presente. 

Se  ha  empleado  la  vacuna  estafilococica  y  auto-vacunas  de  ge*rmenes 
di  versos. 

Dos  panoftalmias,  en  las  que  se  ha  podido  evitar  la  enucleaci6n  y 
conservaci6n,  y  alguna  agudeza  visual  en  una. 

Pero  donde  las  vacunas,  como  se  ve  por  los  casos  anteriormente 
citados,  han  alcanzado  un  importante  y  brillantisimo  papel,  ha  sido 
en  las  afecciones  corneales,  precisamente  las  ma's  temidas. 


558  ROVIROSA  VIRGILI 

La  rapidez  de  la  cicatrization  que  hemos  podido  observar,  la  falta 
de  huellas  cicatrizales  y  la  conservation  funcional,  ponen  a  las  vacu- 
nas,  en  primer  lugar,  en  el  tratamiento  de  las  queratitis  ulcerosas. 

Se  ha  empleado  la  vacuna  estafilococica  y  pneumococica. 

For  lo  tanto  se  han  ensayado  en  esta  experiencia  las  vacunas 
estafilococica  polivalente,  la  pneumococica,  y  las  auto-vacunas  strep- 
tococica,  estafilococica  y  una  del  grupo  difterico. 

En  oftalmologla,  como  en  las  demas  ramas  de  la  Medicina,  se  im- 
pone  hoy  el  diagnostic©  bacteriologico  de  los  procesos  infectivos  y, 
sobre  todo,  los  localizados  6  cronicos,  pues  la  bacterioterapia  ha 
ensanchado  enormemente  el  campo  de  los  tratamientos  especificos ; 
el  tratamiento  bacterioterapico  es  compatible  con  los  demas,  locales 
6  generales,  que  la  experiencia  ha  demostrado  ser  los  mejores,  y  los 
ayuda  haciendo  colaborar  a  la  totalidad  del  organismo  en  el  proceso 
de  curacion  local. 

Las  vacunas  polivalentes  se  emplearan  con  preferencia,  por  ser  de 
mas  comoda  preparation  y,  por  lo  tanto,  mds  economicas;  pero 
cuando  el  proceso  es  poli-microbiano;  cuando  estd,  causado,  por 
germenes  contra  los  que  no  hay  preparada  vacuna  polivalente  6  de 
dep6sito,  y  cuando  ha  fracasado  la  vacuna  polivalente,  deberd  re- 
currirse  a  las  auto-vacunas. 

TRECE  CASOS  DE  ULCERA  SUPURATIVA  DE  LA  CORNEA  TRATADOS 
CON  VACUNA  EsTAFiLoc6ciCA 

Las  queratitis  no  supurativas,  tanto  superficiales  como  profundas, 
ceden  por  lo  general  la  mayoria  de  las  veces  con  un  tratamiento 
apropiado,  pero  no  pasan  las  cosas  en  la  misma  forma  cuando  se 
trata  de  queratitis  supurativas,  que  dividiremos  en  tres  grupos: 
ulceras,  accesos,  y  queratitis  por  desnutricion. 

Solo  voy  a  tratar  aqui  de  las  primeras. 

De  entre  estas  descontaremos  las  queratitis  secundarias  debidas  al 
gonococo,  difteria  y  tracoma,  que  responden  a  una  terapeutica  ya 
estudiada. 

Nos  restan  cuatro  especies  de  queratitis  supurativas  que  son  en  el 
orden  de  f recuencia  las  siguientes :  (1)  Ulceras  debidas  al  estafilococo 
piogeno,  mas  raramente  al  estreptococo;  (2)  ulceras  serpiginosas, 
tfpica  o  atipica,  pneumococica;  (3)  queratomicosis  aspergilar;  (4) 
ulceras  liquidante,  diplobacilo,  de  Petit  de  Rouen,  de  la  que  solo  se 
han  reunido  contadas  observaciones. 

Tanto  la  queratitis  liquidante  como  la  queratomicosis  aspergilar, 


Tratamientos  de  las  Queratitis  Infecciosas  por  las  Vacunas     559 

debida  al  "aspergillus  fumigatus,"  su  paso  por  las  clinicas  es  por 
extremo  raro,  tanto  que  pueden  pasar  anos  sin  que  el  especialista 
observe  un  solo  caso. 

La  queratomicosis  aspergilar  cede  por  lo  general  a  un  concienzudo 
raspado  coadyuvado  por  los  medios  desinfectantes  ordinaries  y  la 
queratitis  liquidante  es  de  esperar  que  ceda  a  la  autovacuna. 

Nos  quedan,  pues,  como  las  mas  frecuentes,  las  queratitis  estafilo- 
cocica, estreptococica,  y  pneumococica;  pero  estas  dos  ultimas  en 
una  proporcion  por  demas  inferior. 

De  este  analisis  se  deduce  que  la  lilcera  estafilococica  es  la  mas  fre- 
cuente  de  todas;  es  la  que  tenemos  cotidianamente  entre  manos,  y 
como  su  gravedad  es  extrema,  de  aqui  la  importancia  de  un  trata- 
miento  como  el  que  tengo  el  honor  de  exponer,  con  el  cual  he  alcanzado 
siempre  hasta  el  presente  resultados  satisfactorios. 

La  queratitis  estafilococica  queda  bien  deslindada  por  sus  caracteres 
clinicos  de  la  ulcera  pneumococica,  a  lo  menos  en  sus  comienzos; 
pero  no  asi  de  la  queratitis  estreptococica,  si  bien  esta  es  sumamente 
rara. 

Por  esto  se  impone  el  examen  bacteriologico,  pues  puede  darse 
tambien  el  caso  de  asociarse  ambas  bacterias  en  el  mismo  proceso. 
Esto,  no  obstante,  siempre  que  sospechemos  por  los  cardcteres  clinicos 
un  caso  de  ulcera  estafilococica,  a  mas  de  obtener  varias  siembras  en 
caldo  aerobic  y  anaerobic  en  agar  y  suero  debe  practicarse  desde  luego 
la  inyeccion  de  vacuna  estafilococica  por  ser  esta  inofensiva,  y  que  casi 
siempre  el  examen  bacteriologico  comprobara  el  aserto,  en  cuyo  caso 
habremos  ganado  un  tiempo  inapreciable,  y  en  el  caso  de  hallarse 
otros  germenes,  puede  continuarse  e'  tratamiento  con  las  auto- 
vacunas  elaboradas  con  dichas  bacterias. 

Los  trece  casos  que  a  continuacion  expongo  de  queratitis  supura- 
tivas  en  todos  la  ulceracion  alcanzo  grandes  dimensiones,  presentando 
abundante  hipopion,  habiendo  por  lo  tanto  llegado  a  mi  clinica  en 
un  estado  de  suma  gravedad,  y  en  los  cuales  se  habian  empleado  los 
medios  ordinarios  sin  resultados.  En  dichos  casos  hay  que  anotar 
las  siguientes  observaciones :  El  caso  septimo,  recomendado  por  el 
Dr.  Rey  Becerra,  corresponde  a  un  enfermo  que  adem&s  de  presentar 
una  extensa  ulceracion  corneal,  con  hipopion,  estd  afecto  de  dacrio- 
cistitis  con  abundante  supuracion,  y  al  que  practique  en  el  acto  la 
extirpacion  del  saco  lagrimal;  no  obstante  la  ulceracion  y  el  hipopion 
siguen  progresando,  a  pesar  de  una  rigurosa  antisepsia,  siendo  ne- 
cesario  aplicar  la  vacuna  al  segundo  dia  de  operado;  la  mejorfa  se 


560  ROVIROSA  VIRGILI 

observa  rapidamente,  y  el  enfermo  ve  hoy  regularmente  gracias  a 
una  iridectomfa. 

El  caso  undecimo,  muy  parecido  al  anterior,  pues  presenta  tambien 
la  enferma  ulcera  con  hipopion  y  dacriocistitis;  pero  en  este  caso  se 
ha  podido  conservar  la  visi6n  sin  necesidad  de  recurrir  a  la  iridectomfa, 
pues  se  le  aplico  la  vac  una  desde  el  primer  momento  antes  de  operar 
el  saco,  y  tanto  el  proceso  corneal  como  lagrimal  cicatrizaron  en  breve 
tiempo. 

El  caso  noveno,  el  mas  grave  de  todos,  lo  recomienda  el  Dr.  Bajo; 
la  lilcera  se  extiende  casi  hasta  los  Ifmites  corneales  y  el  hipopion  tapa 
completamente  el  iris;  despu£s  de  la  aplicacion  de  la  vacuna  cede 
tanto  la  ulceracion  como  el  hipopion  hasta  la  desaparici6n  de  e"sta; 
queda  un  leucoma  adherente,  pero  deja  sitio  para  una  iridectomia 
bastante  extensa. 

El  caso  duodecimo  recomendado  por  el  doctor  Santacana,  que  a 
pesar  de  presentar  una  ulceracion  central  y  extensisima  con  hipopion 
enorme,  apenas  ha  dejado  huella  cicatrizal,  tanto  que  la  enferma  ve 
regularmente  no  obstante  el  leucoma  central,  por  ser  este  muy  diafano. 

CASOS 

1.  Socorro  Pat6n,  de  cuarenta  y  dos  afios,  natural  de  Valdepefias,  ingresa 
el  31  de  Mayo  del  corriente  afio,  afecta  de  ulcera  supurativa  con  hipopi6n. 
Se  le  aplicaron  tres  inyecciones  de  vacuna  estafilococica  polivalente  del 
Laboratorio  Municipal;  leucoma  reducido  en  la  parte  inferior  de  la  c6rnea, 
bastante  transparente. 

2.  Rufina  Garcia,  de  treinta  afios,  de  Casatejada  (Cdceres),  ingres6  el  2 
de  Junio  con  ulcera  supurativa  con  hipopi6n  del  ojo  izquierdo.    Se  le  aplico 
tres  veces  la  vacuna  estafilococica  polivalente.    Leucoma  muy  didfano. 

3.  Pablo  Berlanga,  de  cincuenta  y  siete  afios,  de  Vallecas,  ingresa  el  2  de 
Junio,  presentando  en  su  ojo  derecho  una  extensfsima  ulcera  con  abundante 
hipopion;    se  le  aplicaron  cinco  inyecciones  de  vacuna  estafiloc6cica  poli- 
valente.    Leucoma  adherente.    Iridectomfa  6ptica.    Regular  visi6n. 

4.  Pedro  Sanz,  de  sesenta  y  seis  afios,  de  Cedillo  de  la  Torre  (Segovia), 
ingresa  el  16  de  Julio  con  ulcera  traumdtica  con  hipopi6n. 

5.  Juana  Vifiuelo,  de  cincuenta  y  seis  afios,  de  Puebla  de  Velena  (Gua- 
dalajara), ingresa  el  29  de  Julio  presentando  una  ulcera  con  hipopi6n  ojo 
izquierdo;  se  le  aplic6  la  vacuna  estafilococica  en  los  dfas  24,  26  y  29  de  Julio 
y  2  y  5  de  Agosto.     Leucomo  algo  extenso  pero  muy  transparente. 

6.  Ram6n  Peral  de  cincuenta  afios  de  edad,  de  Navas  del  Rey  (Madrid), 
ingresa  el  27  de  Julio  afecto  de  ulcera  supurativa  con  hipopi6n  en  su  ojo 
izquierdo;  se  le  aplica  la  vacuna  estafiloc6cica  en  los  dias  28  de  Julio,  1,  3, 
y  6  de  Agosto.    El  leucoma  ocupa  el  cuarto  externo  de  la  c6rnea. 


Tratamientos  de  las  Queratitis  Infecciosas  por  las  Vacunas     561 

7.  Gervaso  Sanchez  de  cuarentay  ocho  afios  de  Espinosa  del  Rey  (Toledo), 
ingresa  el  30  de  Julio  afecto  de  dacriocistitis  y  ulcera  con  hipopi6n  en  su  ojo 
izquierdo;  se  le  aplica  la  vacuna  estafiloc6cica  en  los  dias  31  de  Julio,  y  2,  4, 
7,  11,  y  16  de  Agosto.     Leucoma  adherente:  Iridectomfa. 

8.  Esteban  Uceda,  de  cincuenta  y  seis  afios,  de  Brunete  (Madrid),  ingresa 
el  11  de  Agosto  con  una  ulcera  central  con  hipopi6n  en  su  ojo  izquierdo;  se 
le  aplic6  la  vacuna  estafiloc6cica  en  los  dias  12,  16,  18  y  21  del  mismo  mes: 
Leucoma  muy  transparente. 

9.  Narciso  Luengo,  de  cuarenta  y  nueve  anos,  de  Calzada  de  Orepesa 
(Toledo),  ingresa  el  18  de  Agosto  presentando  en  su  ojo  izquierdo  una  ulcera 
extensisima  con  abundante  hipopi6n;  se  le  aplican  cinco  inyecciones  de  va- 
cuna estafilococica:   Leucoma  tercio  inferior  corneal. 

10.  Rosario  Arellano  de  veintocho  afios,  de  Fuensalida  (Toledo),  ingresa 
el  31  de  Agosto  presentando  una  ulcera  con  hipopi6n  en  su  ojo  izquierdo;  se 
le  aplic6  tres  veces  la  vacuna  estafilococica:  Leucoma  transparente. 

11.  Alejandra  Duefias,  de  cincuenta  afios,  de  Ye"benes  (Toledo),  ingresa 
el  4  de  Septiembre  afecta  de  dacriocistitis  y  ulcera  supurativa  con  hipopi6n 
de  su  ojo  izquierdo;  se  le  aplic6  la  vacuna  en  los  dias  6,  8,  10,  13,  y  15  del 
mismo:  Leucoma  inferior  y  transparente. 

12.  Adela  de  la  Pefia,  cuarenta  y  ocho  afios,  de  Zarzalejo  (Madrid),  in- 
gres6  el  10  de  Septiembre  afecta  en  su  ojo  derecho  de  ulcera  central  con 
hipopi6n;  se  le  aplic6  tres  veces  la  vacuna  estafiloc6cica  polivalente:  Leucoma 
muy  didfano. 

13.  Juliana  Serrano,  veintiocho  afios,  de  Palencia,  ingres6  el  11  de  Sep- 
tiembre presentando  en  su  ojo  izquierdo  una  ulcera  supurativa  con  hipopi6n; 
se  le  aplica  tres  veces  la  vacuna  estafilococica  polivalente:    Leucoma  muy 
transparente. 

RESUMEN 

Del  estudio  de  los  precedentes  cases  he  podido  deducir  las  conclu- 
siones  siguientes: 

1.  La  bondad  del  procedimiento ;  pues  en  los  trece  casos  de  ulcera 
corneal  supurativa  a  cual  mds  graves  que  he  presentado,  en  todos  se 
ha  podido  conservar  la  vision;   y  si  a  estos  trece  casos  unimos  los 
cuatro  que  expuse  en  mi  anterior  articulo  sobre  la  bacterioterapfa  en 
oftalmologfa,  suman  diez  y  siete  observaciones  de  queratitis  supurativa 
en  las  que  ha  triumfado  el  tratamiento  por  la  vacuna,  cuando  ya 
habfan  fracasado  los  denies  medios  hasta  aquf  conocidos. 

2.  Que  a  pesar  de  las  dimensiones  exorbitantes  de  la  ulceracion 
que  han  presentado  la  mayoria  de  los  citados  casos,  la  extension  del 
leucoma  no  es  proporcional  a  dichas  dimensiones,  pues  es  mds  pe- 
queno  y  mds  transparente  que  los  leucomas  que  quedan  en  las  ulceras 
tratadas  por  los  medios  ordinaries. 

36 


562  ROVIROSA  VIRGILI 

3.  Que  si  bien  en  la  mayoria  de  los  casos  se  nota  la  mejoria  desde 
el  dia  siguiente  de  la  primera  inyeccion,  hay  algunos  en  que  esta 
mejoria  es  mas  tardia,  sobre  todo  cuando  se  trata  de  procesos  de 
extrema  gravedad,  habiendo  podido  observar  en  dichos  casos  la  re- 
gresion  de  los  smtomas  cuando  mas  inminente  parecia  el  peligro; 
regresion  que  se  fue  acentuando  hasta  quedar  el  ojo  con  una  regular 
vision,  por  lo  que  recomiendo  perserverar,  a  pesar  de  los  fenomenos 
alarmantes  que  presente  el  proceso  hasta  la  quinta  o  la  sexta  in- 
yecci6n. 

Una  rigurosa  antisepsia  local  completara  el  tratamiento. 

Por  lo  tanto  estamos  en  presencia  de  un  agente  terapeutico,  el  mas 
eficaz  en  el  tratamiento  de  las  queratitis  supurativas.  El  mejor, 
por  la  diafanidad  de  las  huellas  cicatrizales  que  se  alcanza  con  su 
empleo,  y  que  es  ademas  completamente  inofensivo. 

APLICACIONES  PRACTICAS  DE  LA  INMUNIDAD  EN  OFTALMOLOGIA 
No  es  nuestro  objeto  hacer  un  estudio  complete  de  la  inmunidad 
en  Oftalmologia,  pero  si  creemos  conveniente  exponer  los  principios 
que  han  guiado  nuestros  estudios  de  bacterioterapia  oftalmica  y  las 
reglas  que  seguimos  en  la  aplicacion  de  las  vacunas,  nuevo  recurso 
terapeutico  que  necesita  manejar  bien  el  oculista. 

La  lectura  del  admirable  trabajo  del  Dr.  Juan  Campos  Fillol, 
Profesor  auxiliar  de  la  Facultad  de  Medicina  de  Valencia,  titulado 
"  Investigaciones  acerca  de  la  cantidad  de  anticuerpos  en  el  suero  de 
la  sangre  y  en  los  humores  del  ojo"  demuestra  cuanta  atencion  deben 
dedicar  al  estudio  de  la  sueroterapia  y  bacterioterapia  especial  oftal- 
mologica  los  que  practican  esta  especialidad  me"dica,  y  aun  los  medicos 
generates . 

El  Dr.  Juan  Campos  ha  demostrado  con  sus  importantes  trabajos: 
(1)  Que  los  anticuerpos  se  encuentran  en  el  humor  acuoso  y  vitreo 
en  cantidad  muy  inferior  a  la  del  suero  sanguineo,  proximamente  en 
la  relation  de  1  por  100;  (2)  que  las  inyecciones  subconjunti vales  y 
otros  estimulos  externos  del  globo  ocular  acrecientan  la  cantidad  de 
anticuerpos  contenidos  en  los  humores  del  ojo;  (3)  la  paracentesis 
corneal  eleva  la  proportion  de  anticuerpos  del  humor  acuoso  entre 
cuatro  y  cincuenta  veces.  En  consecuencia  con  estos  datos,  aconseja 
la  aplicacion  directa  de  los  sueros  antit6xicos  y  bacteriolisicos,  cuando 
necesiten  emplearse  para  combatir  infecciones  oculares,  y  espera  que 
"la  sueroterapia  especifica  y  paraespecifica,  la  autosueroterapia  y 
la  aplicaci6n  de  vacunas,  lo  mismo  profilacticas  que  curativas,  enri- 


Tratamientos  de  las  Queratitis  Infecciosas  por  las  Vacunas     563 

quezcan  el  arsenal  terapeutico  de  la  Oftalmologfa,  proporcionando 
brilliantes  exitos." 

Suscribimos  en  absolute  la  idea  del  Dr.  Campos,  referente  a  la 
aplicacion  directa  de  los  sueros  terapeuticos  al  ojo,  por  ser  el  mejor 
medio  de  llevar  al  foco  del  mal  en  maxima  concentration  las  sub- 
stancias  defensivas  que  los  sueros  contienen.  La  instalacion  fre- 
cuente  de  suero  en  la  conjuntiva  cuando  se  trate  de  procesos  super- 
ficiales  de  la  cornea;  la  inyeccion  subconjuntival  y  hasta  la  intro- 
duction directa  en  la  camara  anterior  del  ojo,  son  los  medios  que  nos 
permiten  obtener  el  fin  deseado. 

Cuando  en  vez  de  suero  se  emplean  vacunas;  cuando  no  se  inyectan 
substancias  defensivas,  sino,  por  el  contrario,  toxicas,  que  obligan 
a  reaccionar  al  organismo,  haciendo  que  el  prepare  los  anticuerpos 
que  necesita  para  destruir  los  germenes  que  le  atacan  y  neutralizar 
sus  toxinas,  entonces  hay  que  inyectarlas  lo  mas  lejos  posible  del  foco, 
en  el  tejido  celular  subcutaneo  6  en  las  venas. 

La  inyeccion  de  vacunas  obliga  a  la  totalidad  del  organismo  a 
colaborar  en  la  defensa  que  realizan  los  elementos  atacados  del  ojo 
y  los  que  aporta  la  sangre,  y  se  fuerza  la  production  de  substancias 
defensivas  que  permiten  yugular  el  proceso  local. 

La  inyeccion  metodica  de  vacunas  provoca  la  aparicion  de  anti- 
cuerpos en  el  suero  de  la  sangre,  principalmente,  por  reaction  de  los 
elementos  del  tejido  conjuntivo:  sangre,  ganglios  linfaticos,  bazo 
y  medula  6sea,  excitados  por  las  substancias  microbianas  que  las 
vacunas  contienen,  y  que  no  se  realiza,  o,  de  verificarse,  es  mucho 
menos  intensa  cuando  el  individuo  que  tiene  una  infeccion  ocular  no 
se  somete  a  este  tratamiento. 

Segiin  el  Dr.  Campos,  la  cantidad  de  anticuerpos  elaborados  por 
la  totalidad  del  organismo  que  pasan  del  plasma  hematico  a  los 
humores  del  ojo,  es  muy  inferior  a  la  que  este  contiene,  e*  indica  que 
artificios  podemos  litilizar  para  aumentar  dicho  paso;  pero  hay  que 
tener  en  cuenta  que  nuestro  companero  ha  experimentado  en  ojos 
normales.  Ha  visto  que  los  estimulos  que  sobre  el  globo  ocular  se 
realizan  elevan  la  proportion  de  anticuerpos  de  los  humores  oculares ; 
teniendo  en  cuenta  estos  datos  y  las  observaciones  clinicas  que  hemos 
publicado  sobre  bacterioterapia  de  las  queratitis  supuradas,  creemos 
que  el  estimulo  que  realiza  la  infeccion  ocular  es  suficiente  para 
atraer  al  ojo  los  anticuerpos  hematicos  en  cantidad  suficiente  para 
neutralizar  la  action  de  los  germenes. 

La  paracentesis  de  la  camara  anterior  es,  segiin  el  doctor  Campos, 


564  ROVIROSA  VIRGILI 

el  mas  poderoso  recurso  de  que  disponemos  para  enriquecer  en  anti- 
cuerpos  hemdticos  el  humor  acuoso.  Nosotros  hemos  podido  evitar 
la  paracentesis  con  la  bacterioterapia  en  casos  en  que  parecia  indicada ; 
no  obstante,  la  reputamos  como  un  excelente  recurso  cuando  se 
acumula  gran  cantidad  de  pus  en  la  cdmara  anterior,  pues  con  ello  se 
libra  al  ojo  de  las  substancias  toxicas  microbianas,  y  de  la  tripsina 
leucocitaria  que  queda  libre  al  destruirse  los  polinucleares,  y  cuya 
accion  sobre  los  tejidos  oculares  es  nefasta.  Ademds,  la  paracentesis 
obra  aportando  anticuerpos  y  elevando  el  poder  antitripsico  del 
humor  acuoso. 

Quizd  se  presente  algiin  caso  en  el  que  la  relativa  dificultad  que 
seiiala  el  Dr.  Campos  para  el  paso  de  los  anticuerpos  de  la  sangre  a 
los  medios  del  ojo,  dificulte  obtener  el  maximum  de  beneficios  que 
puede  reportar  el  empleo  de  las  vacunas;  es  decir,  que  a  pesar  de  la 
intensa  production  de  substancias  defensivas  por  el  organismo,  pro- 
vocada  por  la  inyeccion  de  vacuna,  pasen  en  escasa  cantidad  al  foco 
ocular,  en  el  que  han  de  cumplir  su  accion  anti-infecciosa.  En  estos 
casos,  estarfa  plenamente  indicada  la  autosueroterapfa  de  que  habla 
el  Dr.  Campos;  diez  o  doce  horas  despues  de  extraer  al  enfermo  por 
punci6n  venosa  algunos  c.c.  de  sangre,  se  podria  inyectar  su  suero, 
y  con  el  los  anticuerpos  debajo  de  la  conjuntiva  6  en  la  camara  an- 
terior del  ojo,  sin  miedo  a  ocasionar  reacciones  sericas,  ya  que  precede 
del  propio  individuo. 

De  lo  expuesto  se  deduce  que  la  inmunizacion  activa  terapeutica 
que  realizan  las  vacunas  es  perfectamente  compatible  con  los  medios 
de  accion  local,  cuya  eficacia  ha  comprobado  la  experiencia  y  las 
molestias  que  ocasiona  al  enfermo,  infinitamente  menores  que  las 
ventajas  que  sobre  la  enfermedad  se  obtienen. 

El  empleo  de  las  vacunas  en  Oftalmologia  se  rige  por  las  reglas 
generates  de  bacterioterapia;  ante  todo,  es  necesario  establecer  el 
diagnostic©  etiologico  de  la  infection  ocular.  Unas  veces,  este  diag- 
nostico  se  hard  por  los  medios  de  que  dispone  la  bacteriologia;  pero 
en  otras,  los  caracteres  clinicos  permitiran  suponer  de  que  germenes 
se  trata. 

Por  lo  que  se  refiere  a  las  infecciones  supuradas  de  la  c6rnea,  que 
son  los  procesos  oculares  en  que  hemos  estudiado  prdcticamente  la 
bacterioterapfa,  diremos  que  la  gonococica  comienza  por  una  infiltra- 
tion grisdcea  y  limitada  de  la  cornea,  que  abandonada  a  si  misma,  se 
extiende  rdpidamente  a  la  totalidad  de  la  membrana;  como  caranteres 


Tratamientos  de  las  Queratitis  Infecciosas  por  las  Vacunas     565 

diferenciales,  seiialaremos  lo  enorme  del  gle>osis  conjuntival  y  lo 
abundante  de  la  supuracion  tfpica  de  este  proceso. 

En  la  queratitis  tracomatosa  la  ulceraci6n  es  casi  siempre  mul- 
tiple y  mas  o  menos  profunda,  segun  la  mayor  o  menor  destruccion 
de  la  c6rnea  por  la  lesion  tracomatosa,  siendo  los  sfntomas  diferen- 
ciales el  pannus,  las  granulaciones  6  las  cicatrices  granulosas. 

En  las  queratitis  difterica,  la  ulceracion  se  extiende  rapidamente 
y  va  acorn  panada  de  iritis  e  hipopion. 

Estos  caracteres  clinicos,  unidos  a  los  antecedentes,  nos  permitiran 
casi  siempre  suponer  la  etiologfa  de  esta  clase  de  queratitis. 

De  las  restantes  queratitis  supurativas,  la  mas  frecuente  es  la 
causada  por  el  estafilococo  piogeno,  siguiendo  en  orden  de  frecuencia 
la  queratitis  neumococica,  estreptococica,  diplobacilar,  aspergilar  y 
licuante. 

Por  orden  de  frecuencia,  las  queratitis  debidas  al  estafilococo  y  al 
pneumococo  son  las  mas  importantes,  siendo  muy  distinto  el  sfndrome 
de  unas  y  otras. 

La  lilcera  serpiginosa,  semilunar,  de  base  infiltrada,  6  sea  la  pneu- 
moc6cica,  se  presenta  con  el  caracteristico  borde  en  forma  sigmoidea; 
este  esta  elevado  y  socavado  en  fondo  de  saco,  limpiandose  y  ali- 
sandose  los  bordes  situados  en  el  lado  opuesto  que  se  recubre  de  epitelio 
sin  formacion  de  vasos. 

La  queratitis  estafilococica  se  asemeja,  por  su  aspecto,  a  las  ulce- 
raciones  simples  no  septicas,  de  las  que  la  diferencian  lo  rapido  del 
crecimiento  y  las  tumultuosas  manifestaciones  que  la  acompanan. 
La  infiltracion  ocupa  toda  la  perdida  de  substancia,  al  contrario  de 
la  pneumococica  (ulcus  serpens),  que  avanza  solo  por  su  borde  sig- 
moideo. 

El  hipopion,  inyeccion  ciliar,  dolor,  etc.,  sintomas  que  acompanan 
a  esta  clase  de  queratitis,  no  lo  sefialo,  para  no  distraer  los  caracteres 
verdareramente  diferenciales. 

En  la  queratitis  debida  al  estreptococo,  los  sintomas  son  muy 
parecidos  a  la  producida  por  el  estafilococo,  de  la  que  solo  difiere  por 
su  marcada  propension  a  la  perforacion,  pues  la  infiltracion  invade 
desde  los  primeros  momentos  las  capas  corneales  profundas. 

En  la  queratitis  debida  al  diplobacilo  de  Morax,  la  infiltracion  es 
marginal  y  grisacea,  cede  pronto  al  sulfato  de  zinc  al  3  por  100.  La 
bacilar  de  Weekes  puede  ser  central,  es  superficial,  y  grisacea,  hay 
secrecion  y  cede  a  los  preparados  arge"nticos. 

La  queratomicosis,  debida  al  arpergillus  fumigatus,  presenta  una 


566  ROVIROSA  VIRGILI 

infiltracion  corneal  reducida  al  principio,  andloga  a  una  flictena, 
rodeado  de  bordes  limpios  y  cortantes.  La  queratitis  licuante,  debida 
al  diplobacilo  de  Petit  (Rouen),  es  muy  parecida  a  la  ulcera  serpiginosa 
superficial  o  sea  la  tipica,  pero  se  diferencia  de  esta  por  la  caracte- 
ristica  de  ser  completamente  indolora. 

Conocido  el  germen  causante  de  la  lesion  que  necesitamos  combatir, 
podemos  emplear  una  autovacuna,  o  sea  una  vacuna  hecha  con  los 
propios  germenes  aislados  en  el  enfermo,  o  vacunas  ya  preparadas, 
polivalentes  6  de  deposito.  Las  auto  vacunas  son  mas  eficaces  que 
las  de  deposito  6  comerciales,  pero  su  preparacion  no  es  posible  en 
todos  los  casos,  y  siempre  es  mas  costosa.  Las  vacunas  comerciales 
son  suficientes  en  la  inmensa  mayoria  de  los  casos,  como  hemos  tenido 
ocasion  de  demostrar  en  nuestros  trabajos,  pues  casi  todas  las  observa- 
ciones  son  casos  tratados  con  vacuna  polivalente. 

Las  inyecciones  de  vacuna  provocan  reacciones  que  es  necesario 
observar  atentamente,  pues  ellas  son  los  dates  que  nos  sirven  para 
dirigir  el  tratamiento;  estas  reacciones  son:  local,  general  y  focal. 

Reaccion  local  es  la  que  se  observa  en  el  sitio  en  que  la  vacuna  se 
inyecta,  siempre  de  naturaleza  inflamatoria,  mds  6  menos  intensa, 
segun  la  dosis  de  vacuna  inyectada  y  las  condiciones  individuales. 

La  reaccion  general  consiste  en  malestar,  inapetencia,  insomnio, 
frecuencia  de  pulso,  y  sobre  todo,  elevacion  de  temperatura,  que 
habra  que  observar  con  ayuda  del  termometro. 

La  reaccion  focal  nos  interesa  muy  especialmente,  pues  dada  la 
delicadeza  del  organo  en  que  la  lesion  asienta,  una  reaccion  excesiva 
en  ella  puede  ser  per  judicial.  Nosotros  hemos  tenido  la  fortuna  de 
no  observar  reacciones  focales  perjudiciales,  pues  hemos  procedido 
con  cautela  en  la  elevacion  progresiva  de  la  dosis,  sobre  todo  en  la 
primera  inyeccion  que  sirve  para  tantear  la  susceptibilidad  del  sujeto; 
en  la  primera  inyeccion  hemos  utilizado  siempre  dosis  pequenas, 
inferiores  a  las  que  aconseja  el  preparador  de  la  vacuna  en  las  in- 
strucciones  que  la  acompaiian. 

Cuando  la  inyecci6n  produce  reaccion  local  o  general  muy  fuerte, 
y  con  mayor  motivo  si  se  observa  reaccion  local,  la  dosis  empleada  es 
grande,  y  en  la  inyeccion  siguiente  no  se  aumentara  la  dosis;  se 
repetird  la  que  resulte  fuerte  hasta  que  el  enfermo  la  tolere  bien. 

Procediendo  como  queda  dicho,  hemos  obtenido  los  brillantes 
resultados  publicados  en  los  trabajos  precedentes,  y  que  demuestran 
que  no  es  hoy  especialista  completo  quien  no  sepa  servirse  de  la 
bacterioterapfa,  y  muy  especialmente  para  combatir  la  queratitis 


Carcinoma  of  the  Choroid  567 

supurada,  afecciones  oculares  que  con  mayor  frecuencia  conducen  a 
la  perdida  de  la  visi6n. 

En  fecha  1  de  Junio  de  1915,  registramos  31  casos  de  queratitis 
supurada,  todos  ellos  graves,  en  los  que  habian  fracasado  los  medios 
terapeuticos  habituales,  y  que  la  bacterioterapia  nos  permitio  curar 
rapidamente;  a  pesar  de  las  enormes  dimensiones  de  la  ulceracion 
que  presentaban  la  mayoria  de  los  citados  casos,  la  extension  del 
leucoma,  que  se  produjo  al  curar  no  es  proporcional  a  dichas  dimen- 
siones: es  mas  pequeno  y  transparente  que  los  producidos  despue"s 
de  ulceras  tratadas  con  los  medios  ordinaries. 

Hoy,  en  el  dia  de  la  fecha,  la  estadistica  se  remonta  a  472  casos 
tratados  por  las  vacunas  y  en  los  que  se  ha  comprobado  los  resultados 
satisfactorios  precitados. 


CARCINOMA  OF  THE  CHOROID 

DR.  ALLEN  GREENWOOD 
Boston,  Mass. 

Metastatic  carcinoma  of  the  choroid  is  such  an  infrequent  mani- 
festation of  a  general  carcinosis  that  the  chance  to  see  and  follow  more 
than  one  case  but  rarely  falls  to  the  lot  of  an  ophthalmologist.  The 
opportunity  which  has  come  to  the  author  to  follow  four  cases  makes 
it  seem  worth  while  to  publish  them. 

The  first  case,  that  of  a  man,  W.  G.  C.,  was  published  fully  in  the 
Boston  Medical  and  Surgical  Journal  by  Greenwood  and  Southard1  in 
1903,  including  the  results  of  a  postmortem  examination  and  an  ex- 
haustive microscopic  examination  of  all  metastatic  growths.  At 
that  time  29  cases  of  metastatic  carcinoma  of  the  choroid  had  been 
reported.  Later,  Oatman,2  Parsons,3  and  Krukenberg4  brought  the 
number  of  cases  up  to  41  and  in  1908  Suker  and  Grosvenor5  brought 
the  number  up  to  64.  Since  then  a  number  have  been  reported. 

On  reference  to  the  author's  report  of  his  first  case,  it  will  be  seen 
that  the  patient  came  to  the  hospital  on  account  of  acute  glaucoma 

1  Greenwood  and  Southard:  Boston  Med.  and  Surg.  Jour.,  1903. 

2  Oatman:  Am.  Jour.  Med.  Sci.,  March,  1903. 

3  Parsons:  Royal  London  Ophth.  Hosp.  Report,  xv,  3. 

4  Krukenberg:    Manz-Sattler  Festschr.,  Klin.  Monatsbl.  f.  Augenh.,  1903,  xli 
145. 

5  Suker  and  Grosvenor:  Trans.  Am.  Acad.  Ophth.  and  Oto-Laryn.,  August, 
1908. 


568  ALLEN  GREENWOOD 

in  the  left  eye.  The  fundus,  after  the  glaucoma  had  been  relieved  by 
miotics,  showed  a  separation  of  the  retina  in  the  upper  temporal 
quadrant,  covering  a  flat,  grayish-white  mass.  A  diagnosis  was  made 
of  sarcoma  of  the  choroid,  but  the  eye  was  not  removed  as  it  was 
suspected  that  other  organs  were  involved,  particularly  the  liver. 
The  ocular  pain  was  easily  controlled  by  cocain  and  miotics.  The 
general  examination  of  this  patient  had  shown  no  evidence  of  any 
tumors  in  other  parts  of  the  body,  except  the  probability  of  an  in- 
volvement of  the  liver,  which  was  enlarged.  Prior  to  his  death  the 
patient  became  mentally  incompetent,  suggesting  an  involvement  of 
the  brain.  The  autopsy  findings  would  indicate  the  prostate  as  the 
original  source  of  the  general  carcinosis.  The  organs  particularly 
involved  in  the  general  disease  were  the  lungs,  pleura,  peribronchial 
lymph-glands,  the  liver,  the  brain,  and  the  eye.  In  this  case,  as  in 
one  other,  the  eye  condition  was  the  first  to  call  attention  to  the 
possibility  of  disease  in  other  parts  of  the  body. 

CASE  II. — Miss  J.  D.,  aged  forty-eight,  cook.  Came  under  observation 
April  12,  1908,  with  the  history  that  the  sight  in  the  left  eye  had  been  dim  for 
several  months  and  lately  had  grown  very  much  worse.  Right  eye  normal. 
Vision  =  20  /20  and  fundus  normal.  Left  eye  had  a  vision  of  hand  motions 
only  in  outer  field.  Fundus  showed  a  retinal  separation  in  the  outer  part 
extending  up  to  the  disc,  and  including  most  of  the  upper  and  lower  part  as 
well.  Through  the  separated  retina  3  d.  d.  temporally  from  the  disc  could 
be  seen  a  white  mass  elevated  centrally  about  3  d.  d.,  which  gradually  flattened 
out  in  all  directions.  The  tumor  was  quite  white  in  the  most  elevated  por- 
tion, giving  the  appearance  as  though  a  disc  of  some  substance  like  cheese 
had  been  inserted  under  the  retina.  Immediately  the  similarity  of  the 
fundus  picture  to  that  seen  in  Case  I  came  to  mind  and  questioning  the 
patient  brought  out  the  history  that  for  a  year  there  had  been  a  hard  lump  in 
the  left  breast  and  she  had  become  very  short  of  breath.  She  had  seen  no 
physician  so  was  sent  to  one  who  reported  cancer  of  left  breast,  involving 
left  lung  and  the  axillary  glands;  therefore,  unoperable.  Seen  again  August 
4,  1908,  complaining  that  the  right  eye  had  a  spot  of  dimness.  Right  eye 
examination  showed  up  and  out  from  the  disc  awhitish,  flatmass  about2  d.  d. 
in  size  with  retina  over  it  elevated  1  D.  This  tumor  beneath  the  retina 
corresponded  in  all  but  size  to  the  one  seen  in  the  left  eye  in  April.  The  left 
eye  showed  at  this  time  complete  retinal  separation  and  opaque  striae  in  lens. 
Tension  was  normal  in  both  eyes.  I  next  saw  the  patient  in  consultation  at 
the  Waltham  Hospital  in  October,  1908,  she  having  been  taken  there  on 
account  of  her  weakened  general  and  mental  condition.  I  found  her  semi- 
conscious and  incoherent.  The  tumor  mass  in  the  right  eye  had  increased 


Carcinoma  of  the  Choroid  569 

to  more  than  double  its  former  size  and  was  elevated  at  its  highest  point  4 
d.  d.  and  extended  to  the  disc. 

The  left  eye  showed  a  retinal  separation  up  against  a  cloudy  lens.  The 
patient  died  several  weeks  later  from  cerebral  involvement. 

CASE  III. — Mrs.  J.  S.,  aged  sixty.  Seen  September  12,  1912,  at  her  home 
as  she  was  too  feeble  to  come  to  the  office.  Patient  gave  a  history  of  vision 
failing  for  several  months  beginning  first  in  the  left  eye  and  shortly  after  in 
the  right.  Two  years  before  had  been  through  an  amputation  of  the  right 
breast  and  dissection  of  the  axilla  for  carcinoma.  Had  been  losing  strength 
and  had  a  harsh,  dry  cough  with  much  shortness  of  breath.  Examination 
showed  right  eye  fundus  with  a  flat  retinal  separation  out  and  down.  Retina 
elevated  3  d.d.  about  4  d.d.  down  and  out  from  disc  with  the  elevation  growing 
less  as  one  looked  toward  the  disc,  or  peripherally.  A  white  discoid  tumor 
mass  could  be  seen  through  the  overlying  retina,  but  no  independent  vessels 
were  to  be  seen  and  no  inflammatory  reaction  was  present.  Left  eye  fundus 
showed  extensive  separation  of  the  retina  from  the  disc  outward  and  extending 
somewhat  to  the  nasal  side  above  and  below  the  disc.  The  lower  part  of  the 
separation  was  billowed  forward  by  exudate.  Up  and  out  there  could  be 
seen,  through  the  overlying  retina,  a  grayish-white  mass,  somewhat  uneven, 
the  highest  elevation  being  about  4  D.  This  mass  extended  from  the  tem- 
poral side  of  the  disc,  where  it  was  very  thin,  outward  beyond  the  equator. 
There  was  no  independent  vessel  formation  on  the  mass.  The  pupils  were 
fairly  large  but  tension  not  above  normal.  The  daily  use  of  pilocarpin  was 
advised  with  the  hope  of  preventing  hypertension  and  pain.  The  patient 
died  three  months  later  with  evidences  of  cerebral  involvement  and  prac- 
tically blind,  but  without  the  eyes  becoming  painful. 

CASE  IV. — Mrs.  A.  E.  H.,  aged  thirty-six.  Seen  November  7,  1921,  com- 
plaining that  "something  seems  to  come  frequently  before  the  right  eye  so 
that  print  blurs  and  there  is  a  constant  tendency  to  rub  something  from  the 
right  eye."  Vision  0.  U.  =  20/30.  Patient  is  slightly  myopic.  Examina- 
tion of  fundus,  right  eye,  revealed  a  very  flat  discoid  subretinal  mass  located 
down  and  out  from  the  macula.  It  was  round  and  3  d.  d.  in  size  and  the  upper 
inner  edge  reached  to  lower  border  of  the  macula.  It  was  quite  white,  with 
the  center  whiter  than  toward  the  periphery.  No  independent  vessel  forma- 
tion was  seen  and  no  measurable  elevation  of  the  retina.  No  evidence  of 
inflammatory  reaction  to  its  presence.  The  visual  field  showed  a  partial 
scotoma  up  and  in.  A  more  extensive  examination  of  the  field  was  not 
attempted  at  this  time  on  account  of  the  patient's  poor  physical  condition. 
From  these  appearances,  which  were  similar  to  those  in  Cases  I,  II,  and  III, 
a  diagnosis  of  carcinoma  of  the  choroid  was  made  and  then  the  history  was 
obtained  of  operations  for  mammary  carcinoma  April  2,  1920,  and  October  4, 
1920,  at  the  Massachusetts  General  Hospital.  A  few  days  later  an  x-ray 
examination  at  the  hospital  showed  extensive  involvement  of  the  left  lung. 
Efforts  were  made  to  have  additional  examinations  but  this  has  not  been 


570  ALLEN  GREENWOOD 

possible  owing  to  the  patient's  mental  and  physical  condition,  which  has 
grown  rapidly  worse.     (Seen  in  consultation  with  Dr.  Wm.  E.  Fay.) 

A  study  of  these  cases  discloses  several  facts  worthy  of  mention. 
In  all  four  cases  either  an  autopsy,  an  x-ray  or  physical  signs  showed 
involvement  of  the  lungs.  With  the  lungs  involved,  it  is  easy  to 
understand  how  cancer  emboli  can  be  taken  up  by  the  pulmonary 
vein,  carried  to  the  heart  and  thence  through  the  arteries  to  the 
.  meninges,  choroid  and  other  parts  of  the  uveal  tract.  The  lungs  be- 
come involved  either  by  direct  extension,  as  from  a  mammary  car- 
cinoma, or  through  the  lymphatics  and  the  pulmonary  arteries.  The 
presence  of  cancer  emboli  in  the  arterial  circulation  is  well  illustrated 
by  the  case  of  Ishihara,1  who  described  a  primary  mammary  car- 
cinoma with  multiple  carcinomatous  emboli  in  the  choroidal  capil- 
laries. There  were  three  isolated  tumor  nodules  in  the  choroid  and 
eleven  distinct  capillary  emboli  composed  of  carcinoma  cells.  In 
one  of  Weeks'2  cases  an  eye  with  a  choroidal  tumor  was  removed 
and  the  growth  found  to  be  carcinomatous  with  the  primary  source 
in  the  lungs  only  discovered  at  autopsy.  A  great  many  of  the  cases 
so  thoroughly  tabulated  by  Suker  and  Grosvenor  showed  an  involve- 
ment of  lungs  when  the  records  indicated  a  thorough  general  post- 
mortem examination. 

The  author  queries  as  to  how  often,  if  ever,  a  choroidal  carcinoma 
occurs  until  after  some  involvement  of  the  lungs.  The  discovery, 
therefore,  of  a  whitish  discoid  subretinal  tumor  with  moderate  or 
little  elevation  of  the  retina,  no  independent  vascular  system  and  no 
surrounding  inflammatory  reaction  of  the  retina,  should  lead  to  a 
careful  examination  of  the  lungs,  especially  by  the  use  of  the  x-ray. 

In  the  author's  first  case,  the  tumor  was  diagnosed  as  a  sarcoma. 
This  has  frequently  been  the  case  and,  if  the  patient  is  first  seen  after 
the  onset  of  pain  and  hypertension,  is  to  be  expected.  Hypertension 
is  not  the  rule,  as  in  sarcoma,  even  when  the  eye  is  extensively  in- 
volved. In  my  last  three  cases,  including  five  eyes,  hypertension 
was  not  present.  How  much  the  daily  use  of  a  miotic  may  have  to 
do  with  preventing  this  painful  complication  can  only  be  conjectured. 
In  Case  I  pain  and  hypertension  after  arising  were  made  to  disappear 
by  the  use  of  cocain  and  miotics  sufficiently  to  prevent  any  necessity 
of  enucleation.  Pain  and  hypertension  are  the  only  complications 
which,  if  unrelieved  by  treatment,  call  for  an  enucleation  of  the  eye, 

1  Ishihara:  Klin.  Monats.  f.  Augenh.,  liii,  127. 

2  Weeks:  Am.  Ophth.  Soc.,  1915,  xiv,  326.     Arch.  Ophth.,  xliv,  554. 


Carcinoma  of  the  Choroid 


571 


unless  one  is  in  doubt  as  to  the  differential  diagnosis  between  meta- 
static  carcinoma  and  sarcoma  and,  in  such  a  case,  the  removal  should 
only  be  advised  after  an  exhaustive  physical  and  x-ray  examination 
has  proved  negative  as  to  carcinoma.  It  is  possible  that  the  more 
extensive  pushing  forward  of  the  vitreous  due  to  the  greater  projec- 
tion of  sarcomata  tends  to  increase  the  liability  to  hypertension  while 
the  flat  carcinoma  masses,  even  when  extensive,  do  not  encroach  so 
much  or  so  rapidly  on  the  vitreous  space  and  thus  lessen  the  liability. 


DIFFERENTIAL  DIAGNOSIS 


Situation. 
Shape. . . 


Color 

Projection. 
Growth.  . 


New  vessel 
formation 
Retina. . 


Vision . 


Tension . 


Metastatic  Carcinoma 
.  Posteriorly,  usually  temporally 

and  not  far  from  the  macula. 
.Flat  discoid  with  thin  edges — 

rarely  elevated  more  than  2  or 

3  mm. 
.  Gray  or  white,  without  pigment. 

.Very  little  if  any  projection  into 

the  vitreous. 
.  Spreads  rapidly  in  all  directions 

and  ultimately  surrounds  the 

disc  but  always  flat. 

.  Not  present. 

.Very  slightly  projected  at  first 
by  the  tumor  growth  and  with 
little  subretinal  fluid — separa- 
tion of  the  retina  around  the  tu- 
mor comes  quickly  and  spreads 
rapidly  as  the  tumor  grows  and 
soon  becomes  complete. 

.Early  disturbed  and  soon  lost 
owing  to  rapid  growth  under  or 
toward  the  macula. 


.Not  usually  increased  in  early 
stage  and  usually  amenable  to 
miotics. 


Enucleation ....  Almost  never  necessary  and  of 
no  value  to  the  patient  unless 
for  otherwise  unrelieved  pain — 
does  not  prevent  metastases. 

Occurrence Always  metastatic  and  primary 

focus  or  other  metastases  can 
usually  be  found — often  bi- 
lateral. 

Treatment Palliative. 

Prognosis Inevitably  bad. 


Sarcoma 

Usually  equatorially,  or  far- 
ther forward,  rarely  near  disc. 
Rounded,  nodulated. 


Usually  dark  gray  or  showing 
much  pigment  and  mottled. 

Projecting  far  into  the  vitre- 
ous early. 

As  size  increases  slowly  pro- 
jects more  and  more  into 
vitreous. 

Usually  present. 

Projected  into  the  vitreous 
early  by  the  tumor  and 
separation  of  the  retina 
around  the  tumor  comes 
slowly  and  does  not  become 
complete  until  much  later. 

Vision  centrally  not  early  dis- 
turbed and  not  quickly  lost 
unless  glaucoma  appears — 
eyes  with  sarcoma  often 
enucleated  with  vision  nor- 
mal. 

Usually  raised  early  and  acute 
glaucoma  almost  inevitable 
if  eye  not  enucleated  early 
enough — not  affected  favor- 
ably by  miotics. 

Always  necessary  as  early  as 
possible  and  of  great  value 
to  the  patient  in  preventing 
metastases. 

Always  primary — seldom,  if 
ever  bilateral  and  causes 
metastases  later. 

Early  enucleatiqn. 

Usually  good,  if  seen  early, 
though  metastases  of  the 
liver  may  occur  years  later. 


572  ALLEN  GREENWOOD 

It  is  not  possible  to  arouse  much  interest  in  such  an  absolutely 
hopeless  condition,  but  one  should  be  on  the  lookout  for  these  cases, 
particularly  as  they  seem  to  be  on  the  increase.  Finding  an  eye, 
therefore,  that  presents  a  discoid  white,  or  grayish-white,  subretinal 
mass  located  temporally  not  far  from  the  macula,  with  the  overlying 
retina  only  elevated  2  or  3  D.  at  the  most  and  no  evidence  of  inflam- 
matory reaction,  or  independent  vascular  system,  particularly  in 
women,  would  be  suspicious  of  metastatic  carcinoma,  remembering 
that  such  tumors  rarely  need  enucleation. 

In  spite  of  an  attempted  differential  diagnosis  cases  will  occur  later 
where  an  eye  will  be  enucleated  for  sarcoma  when  the  tumor  is  a 
metastatic  carcinoma.  In  the  author's  first  case  this  would  have  oc- 
curred but  for  the  evidences  of  an  enlargement  of  the  liver.  It  is 
doubtful  if  the  reverse  is  ever  found,  viz.,  that  a  tumor  having,  after 
careful  study,  been  diagnosed  as  carcinoma,  later  turns  out  to  have 
been  sarcoma.  This  fact  should  be  borne  in  mind  when  making  a 
differential  diagnosis.  Therefore,  when  a  tumor  having  all  the  char- 
acteristics described  above  as  being  indicative  of  carcinoma  is  so 
diagnosed  and  later  the  patient  succumbs  to  what  is  very  evidently  a 
general  carcinosis,  especially  if  with  evident  lung  and  brain  involve- 
ment, it  may  be  safely  considered  that  the  correctness  of  a  diagnosis 
of  metastatic  carcinoma  of  the  choroid  has  been  established,  even  if  a 
microscopic  study  of  the  eye  or  a  general  postmortem  be  not  made. 

DISCUSSION 

DR.  GEORGE  E.  DESCHWEINITZ  (Philadelphia):  At  Dr.  Greenwood's 
request  I  exhibit  a  specimen  of  metastatic  carcinoma  of  the  choroid,  the 
eyeball  having  been  enucleated  twenty-five  years  ago.  The  patient,  a  single 
woman,  had  carcinoma  of  the  left  breast,  which  was  thoroughly  removed. 
Six  months  later  vision  of  the  left  eye  became  indistinct  and  examination  re- 
vealed a  flat  carcinoma  of  the  choroid.  The  patient  died  three  months  later, 
metastasis  to  the  brain  and  lower  end  of  the  spine  having  occurred. 

The  tumor  was  composed  of  epithelial  cells,  rather  spheroidal  in  shape,  with 
large  nuclei,  collections  (here  and  there)  of  small  cells  representing  necrotic 
foci,  pigment  granules  and  a  moderate  amount  of  stroma.  In  some  portions 
the  carcinoma  cells  were  arranged  in  long  tubules,  separated  by  faint  stromal 
tissue,  which  contained  pigment  granules.  A  similar  appearance  has  been 
described  by  Lagrange.  In  the  region  of  the  choriocapillaris,  remnants  of 
original  choroidal  structure  were  visible,  also  vessels  plugged  with  cancer 
cells.  The  optic  nerve  and  retina  were  normal;  there  was  no  change  in  the 
filtration  angle. 

A  second  case  examined  at  about  the  same  time  concerned  a  married 
woman,  aged  forty-three,  whose  left  breast  was  removed  for  carcinoma;  re- 


Metastatic  Thyroid  Tumor  in  the  Orbit  573 

currence  in  loco,  in  the  other  breast  and  in  the  axilla  occurred.  The  recurrent 
growths  were  excised;  ten  months  later  dimness  of  vision  of  the  left  eye  was 
noted,  and  the  typical  appearances  of  metastatic  carcinoma  were  found.  The 
patient  also  had  carcinoma  nodules  above  the  left  clavicle.  The  patient  was 
seen  only  once,  and  her  subsequent  history  is  unknown. 


METASTATIC  THYROID  TUMOR  IN  THE  ORBIT 

DR.  ARNOLD  KNAPP 

New  York  City 

Cohnheim  was  the  first  to  recognize  that  a  struma  may  cause 
metastases,  and  called  them  metastatic  benign  strumas.  These  metas- 
tases  occur  in  the  bones  and  in  the  lungs.  Why  they  seem  to  select 
the  bones  is  unsettled;  A.  Miiller  believes  that  the  medulla  of  the 
bone  furnishes  a  favorable  site  for  their  growth  because  of  its  retarded 
circulation.  Thyroid  gland  cells  are  unusual  in  that  they  may,  after 
entering  the  circulation,  remain  viable,  and  in  certain  places  prolife- 
rate and  form  tumors.  Trauma  plays  here  a  definite  r61e.  Striking 
is  the  destructive  power  of  these  metastases,  which  is  particularly 
evident  in  the  bones.  This  destructive  tendency,  the  formation  of 
metastases,  and  recurrences,  cause  some  authors  to  regard  them  as 
essentially  malignant.  The  thyroid  in  some  of  these  cases  seemed  per- 
fectly normal.  The  tumor  may,  of  course,  be  overlooked  in  the  thy- 
roid gland. 

Schmidt  (Zur  Kasuistik  und  Statistik  der  Knochentumoren  mit 
Schilddriisenbau,  Inaug.  Diss.,  Rostock,  1906)  has  collected  49  cases 
of  struma  metastases.  In  the  metastasis,  careful  search  reveals  a  car- 
cinomatous  part  in  the  normal  thyroid  gland  tissue.  The  site  of  these 
metastatic  thyroid  gland  tumors  is  in  various  bones,  particularly  the 
cranial  bones.  Twenty-nine  metastases  occurred  in  the  skull,  princi- 
pally in  the  frontal  and  parietal  bones;  in  the  vertebrae,  16;  in  the 
ribs  and  shoulders,  4;  in  the  pelvis,  11;  in  the  femur,  7;  in  the 
humerus,  6.  The  size  varies  from  that  of  a  fist  to  an  egg.  The  age  of 
the  patient  is  between  30  and  60.  It  affects  women  more  frequently 
than  men.  Trauma  was  elicited  in  11.  From  the  standpoint  of  the 
histology  of  the  tumor  and  the  clinical  course,  the  struma  metastases 
were  malignant  in  39 ;  uncertain  in  5;  possibly  benign  in  5. 


574  ARNOLD  KNAPP 

The  following  is  an  instance  of  this  form  of  tumor: 

Case  Report. — E.  R.  B.,  aged  66;  Dec.  18, 1917:  Has  always  been  in  good 
health  until  recently.  Has  complained  of  vertigo  and  comes  on  account  of  dis- 
comfort in  reading.  Vision  with  glasses,  20  /20.  Both  eyes  seem  unduly  promi- 
nent. The  right  upper  lid  droops  and  the  right  eye  is  distinctly  more  prominent 


Fig.  1. — Metastatic  thyroid  tumor  in  the  orbit. 


than  the  left.  Exophthalmometer — R.  32,  L.  28.  The  motility  of  the  right  eye 
upward  is  restricted,  particularly  in  abduction  (superior  rectus) .  Distinct  ver- 
tical diplopia,  increasing  upward  and  to  the  right.  This  diplopia  patient  was 
observed  for  one  week.  On  palpating  the  right  upper  orbital  margin  there  is 
a  resistance  to  be  felt,  especially  in  the  region  of  the  pulley,  which  consists  of 
a  soft  mass  within  the  upper  margin  of  orbit,  occupying  a  round  defect  in  the 
bone,  where  pulsation  can  be  felt.  The  pulley  is  displaced.  Optic  nerve  nor- 


Metastatic  Thyroid  Tumor  in  the  Orbit  575 

mal.  Field  normal.  The  blood  count  is  normal;  hemoglobin,  9(J  per  cent. 
The  Wassermann  test  is  negative. 

The  Roentgen  examination  shows  an  area  of  increased  radiability  on  the 
right  side,  indicating  an  area  of  softening.  It  involves  the  orbital  plate  of  the 
frontal  bone  and  extends  above  the  superciliary  ridge.  It  is  about  three- 
quarters  of  an  inch  in  its  widest  diameter.  It  extends  about  one  inch  above  the 
supra-orbital  ridge  and  along  the  orbital  plate  to  the  sphenoid  fissure.  There 
seems  to  be  no  involvement  of  the  frontal  sinus,  but  there  is  a  supra-orbital 
extension  of  the  ethmoid  cells  which  seems  to  be  very  near  indeed  to  this 
area  of  softening.  With  the  exception  mentioned,  we  find  no  indication  of 
disease  of  any  of  the  accessory  nasal  sinuses.  The  skull  is  unusually  thick, 
especially  the  outer  table  of  the  frontal  bone  (H.  M.  Imboden). 

Increasing  doses  of  potassium  iodid  are  prescribed  for  six  weeks  without  any 
change  in  the  tumor.  An  operation  is  advised. 

Feb.  19,  1918,  operation.  Curved  incision  below  the  eyebrow  down  to  the 
periosteum,  which  was  found  continuous  downward  with  a  mass.  Incision 
also  through  the  periosteum  and  the  attempt  made  to  elevate  it.  It  was  so 
firmly  adherent  to  the  underlying  structure  that  this  failed.  The  center 
of  the  mass  seemed  to  be  soft.  The  incision  through  the  periosteum  was 
then  enlarged  and  immediately  a  dark,  hemorrhagic-like  mass  resembling 
granulation  tissue  presented.  The  area  was  fully  exposed,  some  of  the  perios- 
teum removed  and  the  above-described  material  was  scooped  out.  The  cavity 
was  found  in  the  bone  extending  back,  upward  anteriorly  and  laterally. 
Profuse  bleeding  made  it  difficult  to  see,  and  one  had  to  be  guided  by  a 
sense  of  touch.  After  cleaning  out  all  this  soft  material  and  some  of  the 
rough  bone  along  the  margins,  a  rather  well-defined  cavity  was  exposed.  The 
constant  oozing  was  somewhat  controlled  by  packing;  it  could  then  be  seen 
that  in  two  small  places  in  the  upper  wall  the  dura  was  exposed  without 
being  directly  involved.  The  edges  of  the  bony  cavity  were  trimmed  off  and 
the  entire  cavity  packed  with  iodoform  gauze.  The  external  wound  was  left 
open.  Length  of  operation,  one  hour. 

In  brief,  this  seemed  to  be  a  tumor  arising  in  the  medulla  of  the  bone, 
particularly  in  the  anterior  part  of  the  frontal,  where  it  forms  the  upper  wall 
of  the  orbit.  The  cavity  was  filled  with  soft,  dark-red  material.  This  in  the 
lower  part  was  directly  adherent  to  the  periosteum.  A  striking  feature  was 
the  extensive  bleeding,  which  seemed  to  be  general.  The  bony  walls  of  the 
cavity  were  smooth. 

No  reaction  followed  the  operation.  At  the  first  dressing  some  of  the  pack- 
ing was  removed;  considerable  oozing. 

The  specimen  removed  at  operation  was  sent  to  Professor  James  Ewing, 
who  reported  as  follows: 

"The  tumor  (Fig.  1)  of  the  bone  in  the  case  of  E.  R.  B.  proves  to  be  an 
adenoma  of  aberrant  thyroid  tissue.  It  is  rather  orderly  in  structure  and  not 


576  ARNOLD  KNAPP 

very  malignant,  although  in  some  spots  the  alveoli  are  small  and  numerous.  It 
reproduces  thyroid  structure  to  the  smallest  detail,  many  alveoli  containing 
soft  acidophile  colloid  surrounded  by  flat  thyroid  cells.  Many  small  alveoli 
are  exactly  similar  to  the  usual  thyroid  adenoma.  The  stroma  is  scanty  and 
not  vascular. 

"This  tumor  may  arise  from  a  portion  of  thyroid  tissue  originally  present  at 
that  point  in  the  embryo,  or  it  may  represent  a  metastasis  of  an  adenoma  in  the 
thyroid.  The  thyroid  gland  should  be  examined  for  the  presence  of  any  small 
tumor  at  any  point.  I  am  inclined  to  prefer  the  former  hypothesis,  especially 
if  there  is  no  tumor  found  in  the  thyroid. 

"The  prognosis  of  these  cases  is  not  entirely  favorable.  Although  they 
have  been  called  'benign  metastasizing  struma'  they  are  not  always  benign. 
They  recur  locally,  and  the  only  other  case  in  the  skull  which  I  have  seen 
(Jeffries'  case,  in  parietal  bone)  recurred  locally  and  eventually  produced 
metastases  elsewhere.  The  thyroid  was  normal.  Hence  I  recommend  that 
radium  be  inserted  in  the  wound,  as  the  alveoli  penetrate  the  bone  spaces  and 
are  hard  to  reach  by  the  knife.  I  know  of  no  cases  treated  by  radium,  but 
would  expect  this  structure  to  respond  well  (J.  Ewing)." 

February  24th :  All  of  the  packing  is  removed  and  a  radium  tube  27  me. 
protected  by  a  lead  plate  is  introduced  for  four  hours.  The  thyroid  gland 
seems  normal. 

March  1st:  No  reaction,  slight  secretion  superficially;  wound  is  allowed 
to  close. 

April  1,  1918:  The  wound  healed.  A  swelling  remained  at  the  upper  mar- 
gin of  the  orbit  continuous  with  a  bony  mass  externally  just  above  the  ex- 
ternal canthus.  Some  exophthalmos  remains,  measuring  R.  30,  L.  28.  Vision 
is  normal.  Eyeground  normal. 

November  26,  1918:  General  condition  good;  no  change  in  orbit. 

April  8, 1919:  Has  lost  about  30  pounds  in  weight;  complains  of  band  over 
head  and  obscure  abdominal  symptoms. 

July  1st:  R.  31.5,  L.  28.  Diffuse  swelling  in  orbit.  Vision  and  eyeground 
normal. 

October  8th:  Drawing  sensation  in  right  half  of  head.    R.  32,  L.  28. 

December  19th:  The  orbital  condition  is  unchanged.  Diplopia  to  the  right. 
Distinct  soft  pulsating  mass  in  orbit.  A  swelling  had  been  noted  over  right 
scapula  for  some  months  and  patient  complains  of  neuralgia  in  right  groin. 

December  29,  1919:  The  patient  is  referred  to  Professor  James  Ewing, 
who  reports  as  follows: 

"There  is  a  tumor  mass  behind  the  eye  which  causes  distinct  exophthalmos 
and  protrusion  of  the  supraorbital  tissues  of  about  1  cm.  The  body  of  the 
right  scapula  is  largely  replaced  by  a  tumor  mass  about  5  cm.  in  diameter,  as 
shown  by  the  x-ray.  This  tumor  is  of  recent  discovery  and  evidently  growing 
actively.  The  left  lower  portion  of  the  thyroid  gland  is  the  seat  of  a  well- 


Metastatic  Thyroid  Tumor  in  the  Orbit  577 

circumscribed,  rather  firm  tumor  mass  about  4  cm.  in  diameter.  There  is  pain 
in  the  use  of  the  right  thigh  muscles,  which  was  not  investigated,  but  will 
receive  attention  later.  The  x-ray  of  the  right  lung  shows  several  suspicious 
isolated  nodules,  which  I  suspect  are  tumor  nodules,  but  which  cannot  be 
positively  identified  as  such.  Further  x-ray  photos  of  the  lungs  and  bones  will 
be  taken.  The  patient  has  lost  weight,  is  anemic  and  rather  feeble,  and  is 
therefore  distinctly  cachectic.  I  feel  that  the  prognosis  is  unfavorable,  but 
that  some  help  may  come  from  x-ray  and  radium  treatment. 

"I  would  recommend  that  the  tumor  of  the  scapula  be  treated  by  x-ray 
that  the  orbital  growth  be  treated  at  first  by  a  radium  pack,  and  that  the  thy- 
roid tumor  be  treated  by  the  insertion  of  radium  needles.  This  latter  tumor 
is  probably  the  source  of  the  others.  The  scapular  growth  was  treated  this 
afternoon.  We  propose  to  go  after  the  others  slowly,  but  steadily,  avoiding 
undue  disturbance  of  the  patient  (J.  Ewing)." 

The  shoulder  tumor  was  given  eleven  x-ray  treatments  from  December  29, 

1919,  to  May  18,  1920.    A  radiograph  on  January  7,  1920,  showed  a  destruc- 
tive process  in  the  eighth  rib  posteriorly  and  an  area  of  bone  destruction  in 
pubis  to  right  of  symphysis.    On  January  20, 1920,  a  small  area  of  destruction 
was  found  in  the  sixth  rib  posteriorly.    The  right  groin  was  treated  by  x-ray 
four  times  from  January  6  to  May  4,  1920.    Radiograph  on  January  7, 

1920,  showed  dense  shadow  above  manubrium  and  to  the  left  of  about  the 
size  of  a  small  orange,  indicating  the  presence  of  a  calcified  mass  in  the  thy- 
roid gland;  pushing  the  trachea  over  to  the  right. 

The  orbit  was  treated  with  radium  three  times  from  January  19,  1921,  to 
April  27,  1921. 

The  patient,  according  to  Dr.  R.  W.  Lowe,  Ridgefield,  Conn.,  then  grad- 
ually lost  weight,  suffered  from  hallucinations  and  delusions,  and  was  at 
times  mildly  maniacal.  There  was  flatness  over  anterior  and  posterior  chest 
(left) ;  pleuritic  pain,  loss  of  motion  over  chest,  dyspnea,  slight  cough.  Lym- 
phatic enlargement  in  neck  (left  side).  Edema  of  lower  extremities,  increasing 
during  last  two  weeks.  Died  July  21,  1921,  apparently  from  cerebral  hem- 
orrhage. 

In  this  patient  a  tumor  in  the  roof  of  the  orbit  was  the  first  symp- 
tom of  a  malignant  process.  At  operation  destruction  of  bone  by  a 
brownish,  granulating,  tissue-like  mass  was  found  present  and  unusu- 
ally free  hemorrhage  occurred.  The  histology  of  the  tumor  showed  it 
to  be  composed  of  thyroid  gland  tissue.  No  tumor  could  be  detected 
in  the  thyroid  gland  on  palpation.  Symptoms  of  other  metastases 
appeared  one  and  a  half  years  later  and  were  confirmed  by  the  x-ray 
examination  in  the  scapula,  in  the  sixth  and  eighth  ribs,  in  the  lungs 
and  in  the  pubis,  and  at  that  time  a  distinct  tumor  was  discovered  in 
37 


578  ARNOLD  KNAPP 

the  thyroid  gland,  and  the  x-ray  showed  that  it  extended  behind  the 
sternum. 

The  localization  of  these  thyroid  gland  tumors  in  the  walls  of  the 
orbit  is  unusual.  In  the  literature  there  is  a  report  of  a  case  by  von 
Eiselsberg  (Langenbeck's  Archiv,  vol.  xlvi,  p.  440)  of  a  woman  thirty- 
seven  years  old,  who  showed  externally  a  bulging  nodule  in  the  sub- 
stance of  the  parietal  bone,  projecting  inward  and  adherent  to  dura. 
Another  nodule  was  situated  in  the  right  upper  orbital  wall  extending 
through  into  the  skull.  The  sixth  rib  right  and  the  left  humerus  were 
also  involved ;  struma  present  (adenocarcinoma) ;  autopsy  report. 

Jaboulay's  patient  (Bull.  soc.  de  chirurgie  de  Lyon,  1903),  a  female, 
sixty-five  years  old,  presented  a  tumor  in  the  supero-internal  angle  of 
the  left  orbit,  pulsating;  old  swelling  of  the  thyroid  gland.  At  opera- 
tion the  bone  was  found  perforated,  exposing  the  meninges. 

In  the  discussion  of  von  Eiselsberg's  report  (Verh.  d.  d.  G.  f.  Chir., 
1893,  p.  88,  i)  Kraske  said  that  he  had  observed  a  case  where  a  tumor 
occurred  in  the  frontal  bone,  the  patient  also  having  a  struma.  The 
association  at  first  was  not  clear.  At  operation  an  unusual  hemor- 
rhage occurred,  which  is  characteristic  for  this  tumor.  The  tumor  was 
adherent  to  the  dura,  necessitating  excision  of  a  part  of  this  structure. 
The  struma  has  remained  stationary  and  no  other  metastases  ap- 
peared. Microscopically  the  tumor  resembled  thyroid  gland  tissue 
and  was  regarded  as  an  adenoma. 

According  to  von  Eiselsberg  (ibid.,  p.  255,  ii),  though  the  histologic 
structure  of  the  tumor  suggested  adenoma,  the  clinical  picture  is  that 
of  an  adenocarcinoma,  because  whenever  a  tumor  metastasizes,  it 
becomes  malignant. 

The  metastases  of  the  adenocarcinoma  of  the  thyroid  may  show 
normal  thyroid  adenomatous  tissue.  The  metastases  grow  slowly, 
while  the  primary  tumor  in  the  thyroid  is  small  and  escapes  detection. 
The  bone  metastases  should  be  operated  upon,  von  Eiselsberg  believes, 
though  it  is  a  general  rule  in  surgery  not  to  operate  on  bone  metastases. 

The  primary  tumor  in  the  thyroid  is  often  not  found  until  the  char- 
acter of  the  metastases  is  made  known. 


BILATERAL  LYMPHOSARCOMA  OF  THE  ORBIT 
WITH  INTERMITTENT  EXOPHTHALMOS 

WALTER  SCOTT  FRANKLIN,  M.D. 

Clinical  Professor  of  Ophthalmology,  University  of  California  Medical  School 

AND 

FREDERICK  C.  CORDES,  A.B.,  M.D. 

Instructor  of  Ophthalmology,  University  of  California  Medical  School 
San  Francisco,  California 

The  subject  of  orbital  tumors  is  an  ever-increasing  one  which  com- 
prises a  large  field.  The  case  at  hand  has  several  unusual  features 
which  warrant  its  presentation. 

Mrs.  M.  B —  — ,  aged  thirty-three,  was  first  seen  in  1908.  Her  symptoms 
were  those  of  a  refractive  error,  namely,  hyperopia.  The  eyes  were  prominent 
without  any  apparent  etiology.  There  was  no  thyroid  disease  and  all  other 
physical  findings  were  negative. 

August,  1917  (eight  years  later),  patient  returned,  complaining  of  a  slight 
drooping  of  the  left  upper  lid.  She  was  also  under  the  care  of  Dr.  A.  W. 
Hewlett,  Professor  of  Medicine  at  Stanford  Medical  School,  who  was  treating 
her  for  an  acquired  lues.  The  eye  findings  were  as  follows:  Slight  ptosis  of 
left  upper  lid.  No  apparent  paralysis.  Lid  could  be  voluntarily  elevated. 
Right  globe  somewhat  more  prominent  than  left.  (At  this  time  we  did  not 
possess  an  exophthalmometer.)  Movements  of  eyeballs  normal.  Tension  of 
left  eye  32  mm.,  right  24  mm.  No  pupillary  changes.  Fundi  negative.  Perim- 
eter fields,  stereoscopic  vision,  and  color  sense  all  normal. 

The  following  is  an  excerpt  of  the  salient  points  in  Dr.  Hewlett's  report: 

"The  general  physical  examination  in  October,  1916,  showed  the  presence  of 
numerous  crackling  and  musical  rales  in  the  left  back  and  axilla.  Wassermann 
reaction  was  3+.  Sputum  negative  for  tubercle  bacilli.  On  March  3, 
1917,  the  white  blood-corpuscle  count  was  7,400,  with  83%  polymorphonu- 
clear  cells,  6%  lymphocytes,  and  11%  large  mononu clears.  From  March, 
1917,  to  September,  1917,  the  patient  was  receiving  anti-luetic  treatment." 

By  October  of  the  same  year  the  ptosis  of  the  left  eye  had  increased,  with 
a  beginning  exophthalmos  of  3  mm.  The  patient  continued  under  most 
vigorous  anti-luetic  treatment.  November  21,  1917,  the  left  eyeball  became 
prominent.  There  was  a  marked  swelling  of  the  lids  with  chemosis.  The 

579 


580       WALTER  SCOTT  FRANKLIN  AND  FREDERICK  C.  CORDES 

examination  for  leukemia  was  negative,  the  white-cell  count  being  7,500,  with 
81%  polymorphonuclears,  6%  lymphocytes,  and  11%  large  mononuclears. 

December  20,  1917,  the  right  eye  was  beginning  to  show  exophthalmos, 
while  the  left  eye  was  at  its  height  and  with  its  upward  motion  limited.  Eight 
days  later  the  left  was  receding,  and  by  January  15,  1918,  both  eyes  were 
somewhat  improved.  January  20  the  left  eye  was  beginning  to  show  recurrent 
exophthalmos,  while  the  right  continued  receding,  and  on  February  20  the 
left  was  at  its  acme  for  the  second  time,  with  the  right  normal.  On  March  1, 
1918,  the  right  was  again  markedly  exophthalmic,  with  the  left  stationary,  and 
by  March  10  the  left  receded,  leaving  the  right  still  somewhat  swollen. 

When  the  patient  reported  on  April  5,  1918,  the  exophthalmos  of  the  left 
eye  was  beginning  to  recur  for  the  third  time  and  the  right  was  normal.  On 
May  10  the  left  eye  protruded  markedly  and  the  right  was  beginning  to  be 
prominent  for  the  third  time.  As  there  was  no  improvement  by  July  6, 
1918,  the  patient  was  put  to  bed,  and  by  October  2,  1918,  both  eyes  had 
receded ;  the  therapy  was  limited  to  hot  compresses  and  rest  in  bed.  The 
left  fundus  now  for  the  time  showed  a  beginning  optic  neuritis. 

A  month  later  a  circumscribed  nodular  swelling  was  observed  in  the  bulbar 
conjunctiva  at  the  nasal  side  of  the  left  eye.  There  being  a  definite  left-sided 
optic  neuritis,  the  patient  was  sent  to  the  University  Hospital.  A  small 
vesicle  developed  which  was  punctured  and  showed  a  pure  culture  of  staphylo- 
cocci,  the  bacteriologic  diagnosis  being  made  by  Dr.  Karl  Meyer. 

The  family  history  was  negative.  Father  died  at  81  (old  age  and  asthma). 
Mother  living  and  well.  No  Tb,  malignancy,  or  other  familial  diseases. 

Past  history  negative  except  for  the  usual  exanthemata  of  childhood. 

On  January  20,  1919,  the  right  eye  was  still  normal,  but  the  left  showed  for 
the  fourth  time  a  marked  exophthalmos,  and  the  patient  was  again  sent  to 
the  hospital  for  further  detailed  examination. 

Physical  examination  at  this  time  was  entirely  negative.  The  blood  count 
showed  hemoglobin  75% ;  white  blood  cells  9,200;  polymorphonuclears  70% ; 
lymphocytes  26%;  large  mononuclears  4%;  urine  examination  negative; 
stereoscopic  x-ray  examination  of  the  skull  negative;  examination  of  nose: 
no  evidence  of  sinus  involvement;  no  involvement  of  preauricular  or  cervical 
glands. 

EXAMINATION  OF  EYES. — Right  eye  normal.  Left  eye,  marked  edema  of 
both  upper  and  lower  lids,  with  chemotic  conjunctiva  bulging  through  pal- 
pebral  aperture.  The  globe  protruded  markedly,  the  exophthalmos  being  10 
mm.  Entire  conjunctiva  injected  and  chemotic;  at  the  inner  canthus  was  a 
rounded  nodule  about  the  size  of  a  pea,  which  appeared  less  edematous  than 
the  remainder  of  the  swelling.  The  lower  lid  was  overlapped  by  the  growth 
while  the  upper  lid  was  enlarged,  covering  the  superior  third  of  the  mass,  as 
shown  in  the  illustration  (Fig.  1).  The  eye  was  amaurotic  and  showed  a 
secondary  atrophy  of  the  nerve-head.  Under  cocain  anesthesia  a  small  por- 
tion of  the  nodule  was  excised  for  microscopic  examination. 


Bilateral  Lymphosarcoma  of  the  Orbit  581 

The  pathologic  report  of  Dr.  G.  Y.  Rusk,  University  of  California  patholo- 
gist, follows: 

Specimen  consists  of  a  small,  irregular  mass  of  tumor  removed  from  the 
subconjunctival  tissue  overlying  the  left  eyeball. 

Microscopic  examination  shows  the  tissue  to  be  composed  of  a  fairly  uni- 
form small  cell,  approaching  a  lymphocyte  in  size,  but  slightly  larger  and 
showing  less  condensation  of  the  chromatic  material.  A  slight  rim  of  proto- 
plasm can  be  made  out  in  many  of  the  cells.  Mitotic  division  is  observed  with 
fair  frequency,  averaging  about  one  to  a  high  power  field.  Thin-walled  ves- 
sels occur  and  also  some  with  fairly  well-developed  walls.  Extending  from  the 
vessels,  fibers  appear  to  run  for  a  short  distance  between  the  cells.  This  ap- 


RS. 
Fig.  1. — Extent  of  exophthalmos  on  lateral  view. 

pearance,  seen  in  the  hematoxylin  and  eosin  stained  tissue,  was  confirmed  by 
the  use  of  the  anilin-blue  connective-tissue  method.  Away  from  the  vessels 
no  fine  interstitial  reticulum  is  demonstrable.  In  different  areas  the  density 
of  the  cells  varies,  there  being  apparently  some  edema  in  places. 

DIAGNOSIS. — Sarcoma  of  small  round-cell  type,  possibly  lymphosarcoma. 

Later  a  diagnosis  of  lymphosarcoma  was  made'  and  confirmed  by  Drs. 
Whipple  and  Meyer,  of  the  University  Staff,  and  by  Dr.  Ophiils,  of  the  Leland 
Stanford,  Jr.,  University,  Department  of  Pathology. 

January  20,  1919,  the  left  eye  was  enucleated.  It  was  debated  whether  to 
eviscerate  the  orbit  or  do  a  simple  enucleation.  We  decided  to  remove  as 
much  tissue  as  seemed  feasible,  depending  upon  our  operative  findings.  A 
circular  incision  was  made  just  outside  the  limbus  through  the  conjunctiva, 


582       WALTER  SCOTT  FRANKLIN  AND  FREDERICK  C.  CORDES 

which  was  decidedly  indurated.  The  ocular  conjunctiva  was  dissected  back, 
and  the  eyeball  freed  to  the  apex  of  the  orbit.  Muscles  and  nerve  were  then 
severed.  The  internal  rectus  muscle  was  obscured  by  a  soft  cellular  tumor 
mass  which  involved  it  throughout  its  length.  Digital  palpation  of  the  orbit 
showed  the  tumor  mass  to  extend  to  the  apex  of  the  orbit  and  impinge  upon 
the  superior  orbital  fissure.  There  was  no  apparent  bony  involvement  at  the 
superior  nasal  border  of  the  orbit.  Due  to  the  extensiveness  of  the  growth  and 
the  likelihood  of  involvement  of  the  other  eye,  as  indicated  by  the  tumor,  and 
the  practical  impossibility  of  radical  excision,  evisceration  of  the  orbit  was 
decided  as  contraindicated.  All  available  parts  of  the  tumor  were  removed 
and  the  wound  packed. 


Fig.  2. — Anterior  view  with  nodule  at  inner  canthus. 

The  pathologic  report  follows:  The  eyeball  and  tumor  in  the  case  already 
reported  (S.  19.9)  was  received  in  formalin.  The  tumor  mass  was  loosely 
adherent  to  the  ball  except  at  the  edge  of  the  cornea,  where  it  apparently 
merged  with  a  circular  opaque  ring,  completely  encircling  the  cornea.  The 
tumor  measures  3J^  x  2  x  2  cm.  The  eyeball  and  tumor  were  cut  in  the 
horizontal  plane  just  above  the  optic  nerve  posteriorly  and  slightly  above  the 
center  of  the  cornea  anteriorly.  From  the  larger  portion  of  the  bulb  and 
tumor  a  block  of  tissue  through  the  whole  mass  is  taken  and  prepared  for 
microscopic  examination. 

The  details  of  the  tumor  correspond  to  those  already  described  in  report 
S.  19.9.  One,  however,  gets  relationships  in  a  much  more  satisfactory  man- 
ner. Anteriorly  the  tumor  starts  from  the  edge  of  the  cornea  and  is  covered 


Bilateral  Lymphosarcoma  of  the  Orbit 


583 


for  some  distance  by  conjunctival  epithelium.  It  shows  apparently  little 
tendency  to  infiltrate  the  sclera,  and  in  this  region  there  is  some  edema  of  the 
pre-existing  tissues.  The  tumor  as  a  whole  is  somewhat  lobulated,  and  while 
the  main  mass  tends  to  grow  away  from  the  bulb,  yet  between  the  main  mass 
and  the  bulb  there  is  considerable  tumor  infiltration  into  the  loose  cellular 
tissue  present.  Toward  the  posterior  end  of  the  tumor  extensive  infiltration 
of  muscle  is  observed.  Connective-tissue  septa  of  some  size  are  observed  in 
the  posterior  portion  of  the  tumor,  probably  representing  pre-existing  struc- 


Fig.  3. — Gross  specimen. 


Fig.  4. — Cross-section  showing  involvement  of  internal  rectus  muscle. 

tures,  and  these  show  varying  degrees  of  infiltration.  At  the  angle  of  the 
cornea  and  sclera  on  the  side  opposite  to  the  growth  there  is  some  edema,  but 
the  growth  has  not  encircled  the  cornea,  as  was  suggested  by  the  gross  appear- 
ance. As  to  the  eyeball  proper,  the  retina  appears  normal,  the  pigment  tissues 
in  both  the  retina  and  sclera  are  normal,  and  there  is  no  evidence  of  tumor 
having  originated  within  the  orbit.  The  optic  nerve  contains  a  suspicious 
number  of  clustered  cells  in  places,  small  and  round,  which  morphologically 
appear  something  like  the  tumor  cells.  Adjacent  to  the  nerve,  however,  in 


584       WALTER  SCOTT  FRANKLIN  AND  FREDERICK  C.  CORDES 


the  angle  which  it  makes  with  the  sclera  and  on  the  side  opposite  the  main 
tumor  growth  is  considerable  invasion  of  areolar  connective  tissue  with  loosely 
scattered  masses  of  small  cells,  simulating  strongly  the  tumor  type. 

DIAGNOSIS.  —  Lymphosarcoma. 

On  January  25,  1919,  the  patient  received  350  milligram  hours  of  radium  to 
the  left  orbit  (screened  by  }/%  mm.  of  silver  and  1  mm.  of  brass)  and  an  addi- 
tional 300  milligram  hours  on  February  3,  1919.  Healing  took  place  without 
signs  of  recurrence,  although  there  was  considerable  skin  reaction  from  the 
radium. 

April  2,  1919,  the  right  eye  was  negative  to  inspection  and  to  all  tests.   The 


Fig.  5. — A.  (X  581.)  Area  with  connective-tissue  septum,  showing 
lymphoid  character  of  cells.  B.  (X  1000.)  Proportionate  same  area  under 
high  magnification.  Illustrations  show  one-tenth  reduction  of  original  drawing. 

left  orbit  showed  a  small  palpebral  aperture,  slight  symblepharon;  no  visible 
signs  of  recurrence.    The  patient  was  apparently  well  physically. 

Up  to  and  including  April  26,  1921,  the  patient  reported  every  few  months 
for  observation,  and  during  that  time  there  was  no  sign  of  recurrence  on  the 
left  side,  and  the  right  eye  was  normal.  The  examination  on  April  26,  1921, 
showed  V.  R.  E.  1/2.  There  was  no  exophthalmos,  the  exophthalmometer 
reading  being  24  mm.  The  fundus  was  negative  and  the  perimetric  field  for 
white  and  colors  was  normal.  In  July,  1921,  we  were  informed  that  the 
patient  had  died,  death  being  caused  by  an  acute  cardiac  decompensation. 
There  was  an  enlarged  spleen,  extending  down  to  the  pelvis,  accompanied  by 
a  marked  ascites.  Several  months  previous  patient  had  complained  of  a 
chronic  cough,  and  on  one  x-ray  examination  a  diagnosis  of  sarcoma  of  the 
lung  was  made.  On  a  "retake"  the  diagnosis  was  altered  to  that  of  pulmon- 


Bilateral  Lymphosarcoma  of  the  Orbit  585 

ary  lues.  Unfortunately,  because  of  the  religious  creed  of  the  family,  it  was 
impossible  to  obtain  a  postmortem  examination.  Clinically  the  entire  picture 
was  rather  suspicious  of  a  sarcomatosis. 

COMMENT 

The  right  eye  of  the  case  under  discussion  was  presumably  also 
effected  by  lymphosarcoma  as  its  actions  were  identical  to  the  left, 
with  the  exception  of  the  appearance  of  the  nodular  mass.  The 
case  can  justifiably  be  considered  one  of  bilateral  lymphosarcoma. 
Several  unusual  points  are  to  be  noted. 

First,  the  bilateral  occurrence  of  lymphosarcoma,  with  marked 
exophthalmos.  The  occurrence  of  lymphosarcoma  of  the  orbit  is 
rather  infrequent.  Chauvel1  reports  a  single-sided  lymphosarcoma, 
as  does  Wurdemann,2  while  Meller3  describes  a  bilateral  lympho- 
sarcoma. Retrogression  followed  by  progression  was  not  noted  in 
any  of  the  above  orbital  tumors.  Because  of  the  infrequency  of  lym- 
phosarcoma in  the  orbit,  we  had  the  pathologic  diagnosis  confirmed 
by  several  independent  pathologists. 

Bilateral  exophthalmos  due  to  retrobulbar  conditions  is  compara- 
tively rare.  It  generally  occurs  accompanying  exophthalmic  goiter 
and  orbital  varices.  Syphilis  had  to  be  considered  in  this  case,  due 
to  the  triple  plus  Wassermann.  In  Forster's4  case  of  symmetric 
tumors  with  exophthalmos  the  condition  subsided  under  KI.  Bail- 
Hart5  reports  bilateral  symmetric  gummata  of  the  orbit.  Anti-luetic 
treatment  had  no  effect  on  our  case. 

Among  the  other  causes  of  bilateral  exophthalmos  may  be  men- 
tioned serous  tenonitis  (Tersen,  A.,  and  Tersen,  J.6)  and  adenoids 
(Posey7)- 

Infrequent  conditions  to  be  considered  are  the  various  orbital 
tumors.  Bilateral  lymphomata  are  comparatively  frequent.  Becker 
and  Arnold8  reported  a  case  of  bilateral  lymphomata  with  exophthal- 
mos and  orbital  glands  which  healed  through  extirpation.  Gerl- 
lach's9  case,  a  four-and-a-half -year-old  boy,  showed  lymphomata 
of  the  neck,  liver,  breasts,  and  conjunctiva.  •  There  were  double- 
sided  tumors  of  the  orbital  glands.  Autopsy  showed  a  generalized 
lymphatic  involvement.  There  was  symmetric  exophthalmos  of  two 
years'  duration,  which  extirpation  showed  to  be  due  to  lymphoma, 
in  a  case  recorded  by  Bernheimer.10  Guaita's11  patients  showed 
diffuse  lymphomata  of  the  conjunctiva,  as  did  Boerma's.12  Arnold 
believes  these  to  be  due  to  hypertrophy  of  small  lymphatic  groups  of 


586       WALTER  SCOTT  FRANKLIN  AND  FREDERICK  C.  CORDES 

tissue  that  occur  in  the  orbit.  Goldzieher 14  thinks  they  are  due  to 
follicular  tissue  from  the  conjunctiva  that  has  grown  into  the  orbit 
while  Axenfeld15  considers  them  as  misplaced  fetal  lymphatic  tissue. 

A  large  number  of  these  tumors  are  found  in  cases  of  leukemia 
and  pseudoleukemia.  Leber16  reports  such  a  case  of  double-sided 
retinal  hemorrhage,  together  with  numerous  orbital  tumors  in  a  case 
of  leukemia.  Similar  cases  are  also  reported  by  E.  Treacher  Collins,17 
Ostenwald,1*  Deleus,19  Gayet,  M.,20  Reymond,21  and  others.  Ahl- 
strom22  goes  so  far  as  to  claim  that  double-sided  orbital  tumors  are 
always  due  to  leukemia  or  pseudoleukemia.  In  his  case  of  pseudo- 
leukemia  the  orbital  tumors  were  the  first  sign  of  the  disease. 

We  considered  the  possibility  of  lymphomata,  but  all  examinations 
for  leukemia  or  pseudoleukemia  were  negative. 

Among  bilateral  orbital  tumors  is  a  case  reported  by  Henry  Juler23 
of  bilateral,  round,  and  spindle-cell  sarcoma,  while  Major  Kirk- 
patrick's24  patient  had  bilateral  endothelioma  of  the  sarcomatous 
type.  In  Silcock's25  case,  a  girl  of  nine,  the  bilateral  orbital  tumors 
were  round,  all  sarcomata. 

Exophthalmos  of  the  intermittent  type  due  to  circulatory  changes 
in  the  orbit  such  as  telangiectases,  cavernomas,  angiomata,  and 
orbital  varices,  have  been  reported  by  Birch-Hirschfeld  and  Ro- 
meick,26  Saint-Martin,27  Hegner,28  Enroth,29  Alger,30  Dupuy-Dutemps 
and  Marvas,31  Posey,32  Mathus  and  Cerise,33  and  others.  In  none 
of  the  cases  of  intermittent  exophthalmos  was  it  due  to  an  orbital 
tumor,  although  Birch-Hirschfeld34  describes  an  intermittent  increase 
of  exophthalmos  due  to  propagation  of  tumor  cells  in  the  orbital 
veins. 

Another  interesting  feature  in  our  case  was  the  continued  observa- 
tion, post-operatively  for  a  period  of  almost  two  and  a  half  years, 
with  no  signs  of  recurrence  on  the  operated  side  or  the  unoperated 
eye.  It  has  been  observed  a  number  of  times  that  removal  of  a  tumor 
on  one  side  has  been  followed  by  improvement  of  the  unoperated  eye. 
Among  the  more  recent  reports,  Wilder35  and  also  Lustig36  made  the 
same  observation.  The  question  arises  as  to  the  effect  on  the  un- 
operated eye  of  the  massive  doses  of  radium  and  whether  or  not  the 
effect  was  sufficient  to  check  the  tumor's  progression. 

We  have  been  unable  to  find  in  the.  literature  a  case  of  bilateral 
lymphosarcoma  with  intermittent  exophthalmos  of  the  type  described. 


Bilateral  Lymphosarcoma  of  the  Orbit  587 


BIBLIOGRAPHY 

1.  Chauvel:  Gazette  hebdomadaire,  No.  xxiii,  1877. 

2.  Wiirdemann:  Am.  Jour.  Oph.,  iii,  210. 

3.  Meller:  Trans.  Ophth.  Gesell.  in  Wien,  October,  1909. 

4.  Forster:  Zehender's  Monatshefte,  1866. 

5.  Bailliart:   Clin.  Ophth.,  xx,  p.  531. 

6.  Tersen,  A.,  and  Tersen,  J.:  Ann.  d'oculist,  December,  1908. 

7.  Posey:  Oph.  Rec.,  xxi,  p.  296. 

8.  Becker  and  Arnold:  Arch.  f.  Ophth.,  xviii,  ab.  2,  p.  56. 

9.  F.  Gerllach:  Jahrbuch  f.  Kinderh.,  1895. 

10.  Bernheimer:  Report  of  20th  Oph.  Congress,  Heidelberg. 

11.  Guaita:  Trans,  of  12th  Italian  Ophth.  Congress,  Pisa. 

12.  Boerma:  Arch.  f.  Oph.,  xviii,  2. 

14.  Goldzieher:  Wiener  med.  Wochensch.,  1893. 

15.  Axenfeld:  Arch.  f.  Oph.,  xxxvii,  4,  102. 

16.  Leber:  Arch.  f.  Oph.,  xxiv,  ab.  1,  295. 

17.  E.  Treacher  Collins:  Oph.  Hosp.  Reports,  xiii,  248. 

18.  Ostenwald:  Arch.  f.  Oph.,  xxvii,  ab.  3,  203. 

19.  Deleus:  Arch.  d'Opht.,  March,  1866. 

20.  Gayet:  Arch.  d'Opht.,  vi,  15. 

21.  Reymond:  Annali  di  Ottalmol.,  xii,  337. 

22.  Ahlstrom:   Monatsch.  f.  Augenh.,  1904,  ii,   276. 

23.  Juler,  H.:  Trans,  of  Oph.  Soc.  Unit.  Kingdom,  xii,  44. 

24.  Kirkpatrick:  Brit.  Jour.  Oph.,  i,  364. 

25.  Silcock:  Trans.  Oph.  Soc.,  viii,  53. 

26.  Birch-Hirschfeld  and  Romeick:  Klin.  M.  f.  Augenh.,  April,  1912,  411. 

27.  Saint-Martin:  Ann.  d'Oculist,  xii,  p.  353. 

28.  Hegner:  Arch,  of  Oph.,  xlv,  385. 

29.  Enroth:  Jour.  Am.  Med.  Ass.,  Ixvi,  1066. 

30.  Alger:  N.  Y.  Med.  Jour.,  January  27,  1907. 

31.  Dupuy-Dutemps  and  Marvas:  Soc.  d'Oph.  de  Paris,  October,  1913. 

32.  Posey:  Jour.  Am.  Med.  Assoc.,  February  18,  1906. 

33.  Mathus  and  Cerise:  Soc.  d'Oph.  de  Paris,  April,  1908. 

34.  Birch-Hirschfeld:  Arch.  f.  Oph.,  xc,  299. 

35.  Wilder:  Ophth.  Rec.,  xiv,  195  and  327. 

36.  Lustig:  Zeitsch.  f.  Augen.,  October,  1908,  388. 


CHLOROMA 

ARTHUR  J.  BEDELL,  M.D. 

Albany,  N.  Y. 

About  one  hundred  years  ago  the  first  description  of  chloroma  ap- 
peared in  literature.  Since  that  time  cases  have  been  reported  from 
England,  France,  Russia,  Germany,  Austria,  Italy,  Japan,  and  the 
United  States.  Therefore  it  seems  fitting  that  we  should  devote  a  few 
minutes  to  a  disease  that  is  even  yet  subject  to  discussion,  not  only 
from  its  etiologic  standpoint,  but  especially  in  relation  to  earlier 
diagnosis  and  subsequent  treatment,  of  which  we  know  so  little. 

Four  cases  are  here  summarized,  two  of  which  have  never  been  pub- 
lished : 

CASE  1. — J.  L.,  a  boy  eight  years  old,  of  foreign  birth,  entered  the  Albany 
Hospital  December  3,  1906.  The  patient,  semi-comatose,  was  extremely 
emaciated,  and  his  skin  was  yellowish.  The  right  eye  was  proptosed  11  mm., 
with  a  growth  in  the  upper  part  of  the  orbit.  The  lower  orbital  region  was 
outlined,  but  a  freely  movable  mass,  12  mm.  wide,  extended  from  the  outer 
to  the  inner  canthus.  This  mass  was  not  attached  to  either  skin  or  periosteum, 
and  its  posterior  margin  was  not  palpable.  There  were  two  subconjunctival 
hemorrhages.  Complete  ophthalmoplegia  externa.  The  cornea  was  clear. 
There  was  a  marked  optic  neuritis,  with  complete  obliteration  of  disc  outline, 
with  areas  of  white  exudate  along  the  larger  vessels.  Vision  equal  to  fingers 
at  six  feet. 

The  left  eye  was  extremely  prominent,  extending  20  mm.  beyond  the  orbital 
ridge,  with  complete  ophthalmoplegia  externa.  The  veins  surrounding  the 
lids  were  enormously  distended  and  tortuous.  Projecting  beyond  the  superior 
orbital  margin  was  a  firm,  freely  movable,  not  adherent  growth,  which  ex- 
tended deeply  into  the  orbit  and  was  palpable  from  the  supra-orbital  foramen 
outward.  The  conjunctiva  was  markedly  chemotic,  with  numerous  ecchy- 
moses.  The  upper  part  of  the  cornea  was  clear,  but  the  lower  half  showed  a 
superficial  necrosis  and  was  covered  with  a  dry  exudate.  Pupil  5.5  mm.,  not 
reacting  to  light  or  accommodation.  There  was  a  deep  yellowish-gray  reflex 
from  the  fundus.  No  detail;  no  light  perception. 

The  right  ear  showed  swelling  of  the  posterior  superior  canal  wall  with 
tender  mastoid.  The  left  was  almost  the  same.  The  lymphatic  glands  of  the 
neck  were  palpable  with  difficulty  on  the  right  side,  but  on  the  left  they  were 

588 


Chloroma 


589 


visible  as  large  as  peas.    Marked  systolic  thrill  in  the  vessels  of  the  neck. 
No  abnormalities  of  the  lungs. 

Heart  dulness  began  at  the  third  rib  and  extended  on  the  right  side  to  the 
midsternal  line.  Apex-beat  in  the  fifth  intercostal  space,  4  mm.  inside  nipple 
line.  Loud  systolic  murmur  over  pulmonic  area;  second  aortic  sound 
accentuated.  Apical  sound  clear  and  distinct.  Pulse  120;  tension  good. 


Fig.  1. — The  larger  type  lymphoid  cell  in  connective  tissue.     Case  1. 


Moderate  pressure  on  the  sternum  caused  pain.  Liver  dulness  extended 
from  the  sixth  rib  to  the  free  costal  margin.  Spleen  not  palpable.  Dulness 
from  ninth  to  eleventh  ribs.  Abdomen  negative  except  sligh:  distention. 
Inguinal  glands  about  the  size  of  small  peas.  Umbilical,  costal,  and  plantar 
reflexes  normal.  No  knee-jerks. 

Urine  clear,  amber,  acid,  s.  g.,  1020;  no  sugar,  but  a  trace  of  albumin 
without  casts. 


590  ARTHUR  J.  BEDELL 

Blood  examination  made  by  Dr.  A.  T.  Laird  showed :  Red  cell  count,  1,410,- 
000;  white  cell  count,  79,600;  hemoglobin,  30  per  cent.;  and  a  differential 
count  of  6,000  leukocytes  showed  polynuclears,  16.2  per  cent. ;  large  mononu- 
clears,  5.3  per  cent.;  large  lymphocytes,  15.3  per  cent.;  transitionals,  0.8  per 
cent.;  eosinophiles,  0.7  per  cent.;  small  lymphocytes,  33  per  cent.;  neutro- 
phile  myelocytes,  28.2  per  cent.;  eosinophile  myelocytes,  0.5  per  cent. 

Five  nucleated  red  cells  were  noted:  three  were  normoblasts,  two  were 
*  larger  than  normoblasts  and  were  classed  as  megaloblasts.  A  number  of 
degenerated  leukocytes  were  seen,  but  no  record  of  them  was  made. 

The  patient  was  given  chloroform,  and  a  3  cm.  incision  was  made  over  the 
outer  half  of  the  superior  orbital  ridge.  The  entire  orbit  was  found  filled  with 
a  greenish  mass  of  almost  cartilaginous  consistence,  in  part  encapsulated,  no- 
where palpably  adherent  to  the  periosteum.  We  could  outline  the  optic  nerve, 
but  could  not  distinguish  any  of  the  ocular  muscles.  Palpation  to  the  apex  of 
the  orbit  proved  that  the  entire  contents  consisted  of  a  pale  green  tumor 
which  was  diagnosed  as  probably  chloroma. 

The  tissue  removed  was  sent  to  Dr.  R.  M.  Pearce,  of  the  Bender  Labora- 
tory, who  reported  as  follows:  Tissue  from  left  orbit:  Material  consists  of 
three  small  pieces  of  tissue,  the  largest  about  0.5  cm.  in  diameter.  These  are 
irregular  in  shape;  in  part  firm  and  of  light  greenish  color,  and  in  part  soft 
and  pink  in  color.  On  section  they  show  a  uniform,  smooth  surface,  firm  in 
the  green  but  soft  in  the  pink  portions. 

Histology. — The  centers  of  the  nodules  are  composed  of  closely  arranged 
cells  of  the  type  of  the  larger  lymphoid  cell.  These  have  a  deeply  but  slightly 
irregular  staining  nucleus  and  a  small  ring  of  eosin-staining  protoplasm.  As 
a  rule,  they  are  round  or  slightly  oval  in  shape,  but  occasionally  are  irregular, 
resembling  in  a  general  way  the  plasma  cell.  No  multinucleated  cells  are 
seen.  Toward  the  periphery  are  single  fat  spaces  which  have  resisted  the 
general  infiltration.  These  spaces  are  more  abundant  at  the  extreme  periph- 
ery, but  the  tissue  between  is  extensively  invaded  by  the  new  cells.  Only 
here  and  there  are  small  areas  of  uninvolved  fat  tissue  seen.  Here  also  are 
areas,  apparently  at  point  of  periosteal  attachment,  with  considerable  fibrous 
tissue  infiltrated  with  lymphoid  cells  and  more  or  less  hyaline  in  character.  In 
the  center  of  the  nodules  there  is  but  a  faint  reticulum  of  indefinite  arrange- 
ment. Few  blood-vessels  are  seen;  polymorphonuclear  leukocytes  are  not 
present  in  appreciable  numbers. 

Histologic  Diagnosis. — Chloroma. 

Dr.  James  F.  Rooney  saw  the  patient  November  26,  1906,  when  the  blood 
showed:  reds,  1,596,000;  whites,  41,200;  hemoglobin,  30  per  cent. ;  color  in- 
dex, 1  +.  Differential  count  of  400  whites:  polymorphonuclears,  37.9  per 
cent.;  large  mononuclears,  11  per  cent.;  small  mononuclears,  12  per  cent.; 
eosinophiles,  3.1  per  cent.;  myelocytes,  neutrophilic,  32.8  per  cent. ;  myelo- 
cytes, eosinophilic,  7.2  percent.;  5  nucleated  reds,  all  normoblasts;  poikilo- 
cytosis,  many  microcytes  and  macrocytes;  many  degenerated  whites. 


Chloroma  591 

The  patient's  condition  grew  progressively  worse  from  the  date  of  admis- 
sion. Emaciation  was  extreme.  Proptosis  of  both  eyes  more  marked.  On 
the  right  side  the  tumor  mass  increased  2  mm.  in  width  and  the  eyelid  became 
darkly  congested,  with  tortuous,  prominent  vessels.  Vision  almost  totally 
lost.  Pupil  6  mm.,  not  reacting.  No  increase  in  the  retinal  changes.  The 
lower  half  of  the  cornea  of  the  left  eye  was  infiltrated,  and  the  outer  layers 
eroded.  No  fundus  visible;  no  decrease  in  the  chemosis;  veins  more  enlarged. 
No  drainage  from  the  wound.  The  glands  of  the  neck  were  greatly  enlarged, 
on  the  left  side  being  as  large  as  pigeon-eggs.  Veins  of  the  neck  showed  no 
signs  of  thrombosis. 

On  December  10th  the  child  had  a  convulsion,  which  started  with  general 
muscular  tremor  of  the  right  side,  followed  by  marked  contraction  with  turn- 


l. 


Case  1. — The  extreme  exophthal-  Case  2. — Bilateral  exophthalmos. 

mos  of  the  left  eye  with  a  marked  en- 
gorgement and  discoloration  of  the 
eyelids. 

ing  toward  the  left.  The  left  side  was  entirely  paralyzed;  respirations  ster- 
torous; patient  unconscious.  He  rallied,  and  from  time  to  time  seemed  to 
comprehend  things.  He  was  removed  from  the  hospital  and  died  that  day. 
Autopsy  was  not  permitted. 

CASE  2. — Mrs.  N.  G.,  aged  eighteen,  married,  a  Russian  by  birth,  was  ad- 
mitted to  the  Albany  Hospital  April  7,  1909.  Family  and  personal  history 
negative.  Patient  menstruated  from  thirteen  years  of  age  until  one  week 
after  marriage,  July,  1908.  One  month  prior  to  admission  she  first  noticed 
many  small,  hard,  insensitive  lumps  in  each  breast,  which  she  believed  had 
not  increased  in  size.  March  8,  1909,  she  had  "pink  eye,"  from  which  she 
seemingly  recovered;  on  March  27th  her  eyes  began  to  bulge,  causing  pain 
and  attacks  of  blindness. 

The  patient  was  an  undersized,  delicately  built,  poorly  nourished  woman. 


592 


ARTHUR  J.  BEDELL 


The  skin  had  a  peculiar  satiny  texture  and  was  of  grayish-yellow  color.  Sev- 
eral nodules,  about  2  cm.  in  diameter,  which  were  attached  to  muscle  and 
bone,  were  palpable  in  each  breast  and  along  the  sternum.  The  axillary  and 
inguinal  glands  were  enlarged.  The  woman  was  eight  months  pregnant;  a 
systolic  murmur,  audible  over  the  whole  precordium,  was  not  transmitted. 


Fig.  2. — Closely  packed  large  round  or  oval  cells  of  the  lymphatic  series; 
cytoplasm  variable  in  amount,  also  many  cells  having  fine  and  coarse  granules 
resembling  myelocytes.  Case  2.  The  section  of  Case  3  was  practically  the  same, 
except  that  eosinophiles  were  found  throughout. 

These  were  the  only  departures  from  an  otherwise  negative  physical  examina- 
tion, except  for  the  ocular  lesions  and  blood  changes. 

April  8th  the  right  eye  prop tosed  20  mm.;  immobile.  The  upper  lid  showed 
great  dilatation  of  the  blood-vessels,  and  although  it  covered  one-third  of  the 
cornea,  it  could  be  retracted,  while  the  lower  lid  was  covered  with  chemotic 
conjunctiva.  A  definite  tumor  mass,  20  by  12  by  8  mm.,  was  outlined  over  the 
lacrimal  gland,  entirely  in  the  lid,  with  no  deep  attachment.  The  superior 


Chloroma  593 

two-thirds  of  the  cornea  was  clear,  but  the  lower  third  showed  a  dense  inter- 
stitial and  superficial  haze.  Pupil  1.5  mm.  Vision  =  fingers  at  3  feet. 

Left  eye  proptosed  18  mm. ;  small  nodule  in  the  upper  lid  at  the  outer  side; 
cornea  hazy  below;  pupil  4.5  mm.,  stationary.  Vision  =  fingers  at  3  feet. 
A  large  mass  of  grayish  appearance  pressed  the  retina  forward,  and  except  for 
an  occasional  vessel,  obscured  fundus  detail. 

.  Blood  examination  made  by  Dr.  James  F.  Rooney,  April  8th  showed :  reds, 
3,150,000;  whites,  36,500;  hemoglobin,  55.0  per  cent.  Differential  count  of 
300  white  cells:  polynuclears,  15.8  per  cent.;  lymphoblasts,  37.2  per  cent.; 
small  mononuclears,  37.0  per  cent.;  large  mononuclears,  transitionals,  9.0  per 
cent.;  eosinophiles,  0.8  per  cent.;  mast  cells,  0.2  per  cent. 

Five  normoblasts  seen  in  counting  300  leukocytes. 

Four  days  later,  April  12th,  the  condition  was  as  shown  in  the  illustration. 
The  right  eye  bulged  forward  25  mm.,  with  intense  engorgement  of  the  veins 
of  the  lids  and  temporal  regions.  The  tumor  was  now  25  by  12.5  mm.,  axis 
60  degrees,  not  adherent  to  the  skin  or  periosteum,  although  extending  deeply 
into  the  orbit.  The  outer  part  of  the  lower  lid  was  filled  by  an  oval,  unat- 
tached growth,  18  by  9  mm.,  axis  120  degrees.  The  lower  half  of  the  eyeball, 
including  the  entire  cornea,  was  exposed.  The  conjunctiva  was  chemotic, 
with  many  small  ecchymoses,  and  a  small  hypopyon  in  the  anterior  chamber. 
Pupil  2  mm.,  stationary,  tension  normal;  extremely  limited  motion  of  the 
globe ;  vision  =  light  perception. 

Left  eye  proptosed  22  mm.,  with  many  irregular  nodular  masses  in  the  upper 
outer  two-thirds  of  the  orbit,  close  to  the  superior  wall,  but  not  adherent  to  it. 
The  upper  half  of  the  cornea  was  covered  by  a  vein-filled  upper  lid;  the  lower 
half  was  rough  and  infiltrated.  The  bulbar  conjunctiva  was  decidedly  con- 
gested and  the  eyeball  stationary.  The  interior  of  the  eye  was  as  before. 
Pupil,  4.5  mm.;  faint  reaction  to  light;  tension  normal. 

Dr.  Rooney 's  blood  examination,  April  12th,  showed:  reds,  2,200,000; 
whites,  52,000.  Differential  count  of  300  whites;  lymphoblasts,  42.5  per 
cent.;  polynuclears,  10.6  per  cent.;  small  mononuclears,  19. 2  per  cent.;  large 
mononuclears  and  transitionals,  8.0  per  cent.;  eosinophiles,  3.0  per  cent.; 
myelocytes,  0.7  per  cent.;  degenerated,  1.0  per  cent.;  six  normoblasts,  one 
megaloblast. 


The  disease  was  diagnosed  chloroma  by  the  examination  of  breast 
tissue.  This  was  done  before  the  patient  died,  on  April  16th,  after 
premature  delivery  of  a  dead  child.  As  in  many  cases,  persistent, 
uncontrollable  nasal  hemorrhage  was  present  for  several  days  before 
death. 

The  following  is  the  autopsy  report  of  Dr.  Wolbach,  held  April  16, 
1909: 
38 


594  ARTHUR  J.  BEDELL 

Autopsy  limited  to  chest  and  abdomen,  so  that  the  orbits  were  not  investi- 
gated. 

Body  is  that  of  a  short-statured,  slightly  built  white  woman.  There  is  ex- 
treme double  exophthalmos,  and  both  eyeballs  are  reddened  and  covered  with 
pruriform  material  and  crusts.  Breasts  are  large  and  nodular.  The  areolae 
are  deeply  pigmented.  Midline  of  the  abdomen  is  deeply  pigmented.  Rigor 
mortis  is  complete.  Marked  postmortem  lividity  of  dependent  parts.  No 
edema. 

Peritoneal  cavity:  Peritoneum  is  smooth,  moist,  glistening.  Appendix 
normal.  Mesenteric  lymph-nodes  not  enlarged. 

Chest:  Under  surface  of  the  sternum  is  covered  with  many  green  tumor 
nodules,  which  are  situated  on  the  surface  and  beneath  the  periosteum.  The 
intercostal  muscles  on  both  sides  for  a  distance  of  several  centimeters  are 
invaded  and  replaced  by  tumor  tissue  which  completely  surrounds  the  costal 
cartilages  of  the  upper  five  or  six  ribs. 

Pleural  and  pericardial  cavities  negative. 

Heart:  Normal  in  size.  Myocardium  is  of  good  consistence.  Valves  and 
endocardium  are  normal.  There  are  three  tumor  nodules  in  the  auricles  of  the 
heart,  situated  as  follows:  one  in  the  posterior  wall  of  the  left  auricle,  near 
the  interauricular  septum.  This  nodule  is  olive  green  in  color  and  measures 
2  by  1.5  cm.  In  the  interauricular  septum,  just  above  the  mitral  valve,  and 
close  to  the  posterior  border,  is  a  nodule  0.5  cm.  in  diameter,  which  is  pale 
green  in  color.  In  the  wall  of  the  right  auricle,  in  the  posterior  side,  close  to 
the  interauricular  septum,  is  a  similar  nodule,  1  cm.  in  diameter. 

Lungs:  Both  are  negative,  except  for  edema  and  congestion.  At  the  root  of 
the  left  lung,  presumably  in  the  mesenteric  nodes,  are  two  pale  green  tumor 
nodules  about  1.5  cm.  in  diameter. 

Spleen:  Normal  in  color  and  consistence. 

Liver:  Pale,  reddish  brown  in  color,  normal  in  size  and  consistence.  No 
tumor  nodule  found  on  close  inspection. 

Pancreas:  There  is  a  mass  of  large,  green  glands  at  the  head  of  the  pancreas. 
On  section,  these  vary  in  color  from  a  pale  green  to  an  olive  green.  Embedded 
in  the  tail  of  the  pancreas  are  two  similarly  colored  nodules,  about  1  cm.  in 
diameter. 

Gastro-intestinal  Tract:  Not  opened. 

Kidneys:  Both  kidneys  are  normal  in  size,  pale  in  color,  and  each  contain 
many  nodules,  varying  in  size  from  2  mm.  to  1.5  cm.  The  largest  are  situated 
beneath  the  capsule,  and  are  flattened  and  soft  in  consistence.  Smaller  ones 
are  distributed  throughout  from  cortex  to  pyramids,  and  are  firmer  in  con- 
sistence. These  nodules  are  of  rather  pale  color,  but  of  a  decided  green  tint. 
The  larger  ones  show  small  red  areas — presumably  hemorrhages. 

Adrenals:  Both  are  normal. 

Prevertebral  lymph-nodes  are  markedly  enlarged.    On  the  left  side,  just 


Chloroma  595 

above  the  bifurcation  of  the  aorta,  is  a  large  mass  of  pea-green  tumor  tissue 
which  is  firmly  attached  to  the  periosteum  covering  the  vertebrae.  This  mass 
is  roughly  hemispheric  in  shape,  with  a  base  5  cm.  in  diameter  and  a  depth  of 
3  to  4  cm.  Consistence  is  very  firm. 

Genitalia:  Uterus  large  and  has  the  partially  contracted  appearance  of  a 
recent  delivery.  Ovaries  and  tubes  normal.  Owing  to  the  lack  of  time, 
genitalia  were  not  more  closely  inspected. 

Fresh  microscopic  examination  of  the  tumor  shows  it  to  be  made  up  of 
small  round  cells,  a  few  of  which  contain  many  refractive  granules.  The  fluid 
obtained  by  teasing  and  expressing  glands  contains  many  refractive  globules, 
which  on  exposure  to  fumes  of  osmic  acid  turn  dark  brown. 

Breasts:  Both  breasts  and  surrounding  fat  tissue  are  largely  replaced  by 
green  tumor  tissue.  The  growth  consists  of  spheric  and  ovoid  masses,  from  a 
size  just  visible  to  nodules  3  cm.  in  diameter.  These  nodules  are  of  quite  firm 
consistence.  The  color  varies  from  a  pale  green  to  an  olive  green. 

Anatomic  diagnosis:  Chloroma  with  metastases  to  sternum,  heart,  bron- 
chial nodes,  kidney,  pancreas,  and  lymph-nodes. 

CASE  3. — B.  R.,  aged  five  years,  entered  the  Albany  Hospital  April  23, 
1913,  and  was  discharged  May  16,  1913.  The  dominant  symptom  was  a 
firm,  ovoid  growth  occupying  the  upper  one-half  of  the  right  orbit,  producing 
the  effect,  as  shown  in  the  illustration,  of  a  mass  anterior  to  the  eyeball.  The 
skin  was  freely  movable  over  it,  but  the  tumor  extended  deeply  into  the  orbit. 
The  right  eye  was  movable  in  all  directions,  without  fundus  lesion.  The  left 
eye  and  orbit  were  uninvolved.  The  patient  had  a  peculiar  sallow  appear- 
ance. He  had  several  slight  hemorrhages  from  nose. 

The  blood  count  showed:  White  blood  cells,  7,700;  red  blood  cells,  1,930,- 
000;  hemoglobin,  55  per  cent.  (Tallquist);  differential  white  count,  250  cells; 
poly morphonu dear  neutrophiles,  25.6  per  cent.;  small  lymphocytes,  65.6  per 
cent.;  large  lymphocytes,  5.6  per  cent.;  large  mononuclears,  1.6  per  cent.; 
eosinophiles,  0.4  per  cent.;  transitionals,  1.2  per  cent.;  irregularity  in  size  and 
shape  of  red  cells;  no  nucleated  red  seen. 

The  day  of  his  discharge  showed:  White  cell  count,  6,200;  red  cell  count, 
1,510,000;  hemoglobin,  50  per  cent.  (Tallquist);  differential  count,  250; 
poly  morphonu  clear  neutrophiles,  12.8  per  cent.;  small  lymphocytes,  70.4 
per  cent.;  large  lymphocytes,  2.4  per  cent.;  large  mononuclears,  14.4  per 
cent.;  the  red  cells  are  somewhat  irregular  in  shape  and  size.  The  increase 
in  mononuclears  is  noteworthy. 

The  temperature  ranged  from  99°  to  102°  F.  Wassermann  reaction  was 
negative.  Before  the  child  was  taken  home,  where  he  died  June  5,  1913,  the 
right  eye  became  very  prominent,  with  practically  no  motion.  Definite 
masses,  similar  to  that  in  the  upper  lid,  also  appeared  in  the  lower,  filling  the 
orbit.  A  firm,  lobulated  tumor  deep  in  the  left  orbit  produced  marked  exoph- 
thalmos.  The  temporal  region  became  infiltrated.  The  hearing  was  greatly 


596  ARTHUR  J.  BEDELL 

reduced.  There  was  no  marked  glandular  enlargement.  The  patient  died 
with  meningitic  symptoms. 

On  April  26,  1913,  the  patient  was  given  an  anesthetic  and  a  curvilinear 
incision  was  made  close  to  the  superior  orbital  margin.  The  entire  orbit  was 
filled  with  a  firm  green  mass.  Part  was  excised  for  histologic  study,  and  the 
diagnosis  of  chloroma  confirmed. 

During  the  time  of  the  patient's  stay  in  the  hospital  he  was  given  benzol 
without  improvement.  Despite  strenuous  efforts,  autopsy  was  not  permitted. 

CASE  4. — J.  N.,  a  girl  seven  years  old,  of  foreign  extraction,  entered  school 
a  year  ago,  and  seemed  to  be  normal  in  every  way.  After  being  in  school  a 
few  weeks  she  began  to  complain  of  headache  and  would  cry  for  hours.  On 
July  4,  1921,  the  child's  right  arm  was  severely  burned  and  she  was  sick  for 
three  weeks.  On  October  27,  1921,  Dr.  LaSalle  Archambault  sent  her  to  my 


Case  3. — Ovoid  mass  in  the  right  upper  Case  4. — Marked    bilateral    exoph- 

lid  which  extended  far  into  the  orbit.          thalmos  greater  on  the  right  side  with 

temporal  fullness. 

office.  The  right  eye  bulged  forward  11  mm.,  with  limitation  of  motion  ver- 
tically but  not  horizontally.  There  were  several  large,  rounded  masses  freely 
movable  beneath  the  skin,  but  extending  into  the  orbit  and  seemingly  ad- 
herent to  the  superior  orbital  ridge.  There  were  also  masses  in  the  lower  por- 
tion of  the  orbit,  with  the  same  characteristics.  The  pupil  was  6  mm.  sta- 
tionary, media  clear,,  with  an  intense  neuroretinitis,  many  areas  of  whitish 
exudate  and  several  flame-shaped  hemorrhages.  The  left  eye  protruded  8 
mm.,  with  the  same  type  masses  extending  deep  in  the  orbit.  There  was 
definite  swelling  of  the  optic  nerve,  with  retinal  exudate.  In  both  temporal 
regions  there  was  a  firm  swelling  and  the  patient  was  totally  deaf. 

I  sent  her  to  the  Albany  Hospital  with  a  diagnosis  of  chloroma.  This  was 
verified  by  the  blood  examination,  which  showed:  Red  blood  cells,  3,100,000; 
white  blood  cells,  20,800;  hemoglobin,  67  per  cent.;  polymorphonuclears,  19 


Chloroma 


597 


per  cent.;  large  and  small  lymphocytes,  81  per  cent.;  large  mononuclears, 
68  per  cent.  ;  small  mononuclears,  32  per  cent.  ;  benzidene  reaction  shows  the 
lymphocytes  to  be  of  the  myeloblastic  series.  The  second  count,  October  30, 
1921,  showed:  Polymorphonuclears,  21  per  cent.;  large  lymphocytes,  6  per 
cent.;  small  lymphocytes,  12  percent.;  large  mononuclears  with  granular 
cytoplasm  (myelocytes  and  myeloblasts),  54  percent.;  transitionals,  7  per 


Fig.  3.— Blood  smear  from  Case  4.    Wright's  stain,  showing  the  usual  red  blood- 
cells,  polymorphonuclears,  lymphocytes,  and  myelocytes. 

cent.  Oxydase  stain  showed  granular  forms  in  the  ratio  of  9  to  1  non- 
granular. 

Urinalysis:  Color,  amber;  cloudy;  reaction  acid;  sp.  gr.  1017;  albumin 
positive;  sugar  negative;  microscopic — loaded  with  amorphous  urates, 
mucus. 

Tempera.ture,  which  was  on  admission  100.3°,  dropped  to  98°  the  next 
morning,  but  then  rose  above  103°.  The  parents  took  the  child  from  the 


598 


ARTHUR  J.  BEDELL 


hospital  when  they  were  told  that  the  outcome  would  be  fatal.   The  child  died 
at  home  November  9,  1921,  and  it  was  impossible  to  get  an  autopsy. 

In  the  complete  review  of  the  literature  we  find  that  90  cases  have 
been  reported — 25  females,  5  sex  not  stated,  and  the  remainder  males. 
The  age  varied  from  one  year  nine  months  to  fifty-five  years,  by  far 


Fig.  4. — Oxydase  reaction  of  the  blood  of  Case  4,  showing  polymorphonuclears, 
myelocytes,  myeloblasts,  and  nuclei  of  small  lymphocytes. 

the  greater  number  being  in  children  and  young  adults.  The  duration 
of  the  disease  was  so  uncertain  that  even  the  statement  that  many 
died  within  one  month,  some  even  within  four  days  after  the  primary 
visit,  helps  little  in  the  diagnosis.  The  greatest  number  of  cases  were 
only  properly  understood  at  autopsy. 

The  reported  white  counts  varied  from  6,200  to  519,600.    In  only 
six  cases,  however,  was  it  100,000  or  more.    The  commonest  count  is 


Chloroma  599 

less  than  40,000,  and,  as  will  be  noted  in  our  own  cases,  one  count  was 
6,200.  On  the  other  hand,  the  differential  count  gave  information  of 
the  greatest  value,  for  in  all  cases  we  find  a  marked  decrease  in  the 
polymorphonuclears,  with  a  considerable  increase  of  the  myelocytes. 

The  diagnosis  of  this  condition  can  be  made  early.  Every  case  of 
exophthalmos  in  a  child  should  have  an  immediate  complete  blood 
examination,  for,  as  has  been  proved  by  many  and  corroborated  by 
our  cases,  the  first  symptom  is  in  the  blood  change. 

The  treatment  has  ranged  from  benzol  to  x-ray  to  radium.  The 
lack  of  curing  power  when  late,  at  least,  is  evidenced  by  the  fatal  out- 
come of  all  cases. 

To  summarize:  Chloroma,  a  disease  of  the  blood-making  organs, 
lends  itself  to  early  diagnosis  by  its  characteristic  blood  picture.  The 
common  eye  symptoms  are  lid  and  orbital  tumors,  exophthalmos,  sub- 
conjunctival  hemorrhages,  retinal  hemorrhages  and  exudate,  neuro- 
retinitis,  and  blindness,  although  frequently  unilateral,  most  often  the 
changes  become  bilateral  and,  finally,  investigation  will  doubtless 
prove  an  infection  the  origin  of  the  disease,  and  that  such  infection 
will  be  diagnosed  and  cured.  It  is  with  this  hope  that  this  clinical 
communication  is  presented. 

It  is  with  great  pleasure  that  I  acknowledge  my  indebtedness  to 
Dr.  C.  S.  Merrill,  who  so  kindly  made  it  possible  for  me  to  diagnose 
and  treat  Cases  1  and  3;  to  Dr.  G.  Emory  Lochner,  for  giving  me  the 
control  of  Case  2;  to  Dr.  Charles  E.  Allen  for  his  assistance  in  Case  4, 
and  to  Mr.  J.  A.  Glenn  for  the  microphotographs  of  tumors  and  blood, 
and  to  my  able  and  conscientious  assistant,  Dr.  Anton  S.  Schneider. 

REFERENCES 

Alt:  A  Case  of  Chloroma,  Am.  Jour.  Ophth.,  March,  1897,  xiv,  78. 
Aran:  Note  sur  une  forme  particuliere  et  encore  peu  connue  de  cancer  de  la 

Dure  mere  et  des  os  du  Crane  (Cancer  vert,  chloroma),  Arch.  gen.  de  med., 

1854,  385. 
Arnold  and  Becker:    Doppelseitiges  symmetrisch-gelegenes  Lymphadenom  der 

Orbita,  Arch.  f.  Ophth.,  1872,  56. 

Axenfeld:  Zur  Lymphombildung  in  der  Orbita,  Arch.  f.  Ophth.,  1891,  xxxvii,  102. 
Ayers:  A  Case  of  Chloroma,  Jour.  A.  M.  A.,  1896,  xxvii,  986. 
Balfour:   Case  of  Peculiar  Disease  of  the  Skull  and  Dura  Mater,  read  December 

3,  1834,  Edinburgh  Med.  and  Surg.  Jour.,  1835,  319. 
Bedell:  Another  Case  of  Chloroma,  Annals  Ophth.,  July,  1912,  xxi,  452. 
Behring  and  Wicherkiewiez :  Ein  Fall  von  metastasirendem  Chlorosarkom,  Berl. 

klin.  Wochen.,  1882,  No.  33,  509. 
Benjamin  and  Sluka:  Das  Chlorom,  Jahrb.  f.  Kinderh.,  etc.,  1907,  Ixxiii,  87. 


600  ARTHUR  J.  BEDELL 

Berl :  Pseudo-leuksemische  Erkrankung  der  Bindehaut  u.  des  orbitalen  Gewebes, 

Beitrag  z.  Augenheilk.,  1899,  iv,  32. 

Bergmeister:  Ein  Chlorom  der  Orbita,  Zeitschr.  f.  Augenh.,  1909,  xxii,  544. 
Bierring:  Chloroma,  Jour.  A.  M.  A.,  1912,  1434. 
Birk:  Ein  interessantes  Fall  von  Leukamie,  St.  Petersburg,  med.  Wochen.,  1833, 

viii,  377. 

Bock:  Lymphoma  orbitse  sinistrae,  Wien.  med.  Wochen.,  1898,  No.  32,  1559. 
Boots:  Chloroma  with  Report  of  a  Cage,  Jour.  Lab.  and  Clin.  Med.,  1917,  622. 
Bramwell:    Notes  on  a  Case  of  Chloroma  and  of  Three  Cases  of  Lymphatic 

Leukemia,  Scot.  Med.  and  Su'rg.  Jour.,  1902,  x,  219;    Lancet,  London, 

1902,  520;  Brit.  Med.  Jour.,  1902,  ii,  453. 
Bruce:  Chloroma  of  the  Jaws,  Ann.  Surg.,  January,  1910,  52. 
Burgess:   Chloroma,  Jour.  Med.  Research,  1912,  xxvii,  133;  Boston  City  Hosp. 

Med.  and  Surg.  Reports,  1913. 
Burns:    Observation  on  the  Surgical  Anat.  of  the  Head  and  Neck,  Baltimore, 

1823,  386. 
Buschke :   Ueber  ein  Fall  von  symmetrischen  sarkomatosen  Tumoren  der  Schlaf- 

enregiones  und  der  Wangen,  Chlorom,  Berl.  klin.  Wochen.,  1905,  xlii,  1001. 
Butler:  A  Case  of  Chloroma,  Brit.  Med.  Jour.,  April  20,  1907,  929. 
Calderaro  and  Cirincione:  Chloroma  bilaterale  dell  orbita,  Clin.  Oculistica,  1903, 

1417. 

Catalino:  Archives  Espanolas  de  pediatria,  May,  1918. 
Chiari:  Zur  Kenntnis  des  Chloroms,  Prag.  Zeitschr.  f.  Heilk.,  1883,  iv,  177. 
Collins:  On  a  Case  with  a  Tumor  in  Each  Orbit,  Death — Necropsy,  Royal  Lon- 
don Ophthalmic  Hospital  Report,  December,  1891,  248. 
Coppez :  Tumeur  Orbitaire  avec  envahiessement  secondaire  de  la  sclerotique  et  de 

la  cornee,  Arch.  d'Ophtalmologie,  1895,  xv,  544. 
DeGraag:    Lymphatische  Leukamie  und  Chlorom,   Geneeskundige  Bladen  u. 

Klin.,  1904;  Ergebn.  d.  allg.  Path.  u.  path.  Anat.,  760. 
Delens:  Observations  des  tumeurs  lymphadeniques  des  deux  orbits,  Arch,  d'opht., 

1886,  vi,  154. 
Di  Cristina:  Contributo  clinico  ed  anatomico.     Pathologico  allo  studio  del  chlo- 

roma,  Pediatria,  October,  1914,  721. 
Dittrich:  Vierteljahr.  f.  d.  prakt.  Heilk.,  1846,  104. 
Dock:  Chloroma  and  its  Relation  to  Leukemia,  Amer.  Jour.  Med.  Sc..  July,  1893, 

152. 
Dock  and  Warthin:  A  New  Case  of  Chloroma  with  Leukemia,  Trans.  Assn.  Am. 

Phys.,  1904,  64;  Medical  News,  1904,  971. 
Dreschfeld:    Ein  Beitrag  zur  Lehre  von  den  Lymphosarkomen,  Deutsch.  med. 

Wochen.,  1891,  1175. 
Dressier:   Ein  Fall  von  sogenanntem  Chlorom,  Virchow's  Arch.  f.  path.  Anat., 

1866,  605. 
Drozda:    Akutes  Leukamie  mit  eigenartigen  an  Chlorom  erinnerenden  Obduc- 

tionsbefund,  Gesellsch.  f.  inn.  Med.,  October  23, 1902;  Wien.  klin.  Wochen., 

1902,  1236. 
Dunlop:  A  Case  of  Chloroma  with  Pathologic  Report  and  Some  Notes  Descriptive 

of  the  Disease,  Brit.  Med.  Jour.,  1902,  1072. 


Chloroma  601 

Dunn:    Leukemia  with  Rare  Lymphoid  Growths  of  Orbit  and  Parotid  Glands, 

from  Trans.  College  Phys.,  Philadelphia,  1893,  103;   Ophth.  Rev.,  1894, 

No.  151,  167. 

Durand  and  Fardel:  Bull,  de  la  Societe"  anatomique,  March  1,  1836,  xi,  195. 
Eichhorst:    Uber  eigentlimliche  Knochenmarks-Befunde  bei  Chloro-leuksemie, 

Deut.  Arch.  f.  klin.  Med.,  1921,  cxxxv,  129. 
Emden  and  Rothschild:    Uber  das  Chlorom  und  seine  Beziehung  zur  Myelo- 

blastenleukamie,  Deutsch.  Arch.  f.  klin.  Med.,  1914,  304. 
Esser:  Myeloblastenchlorom,  Deutsch.  med.  Wochen.,  1912,  xxxviii,  783;  Myelo- 

blastic  Chloroma,  Sitzungsb.  b.  d.  naturh.  Ver.  d.  preuss.  Rheinl.  u.  West- 

phal,  Bonn,  January  22,  1912,  5. 
Fabian:   Uber  lymphatische  und  myeloidische  Chloroleukamie,  Beitrage  zur  path. 

Anat.  u.  z.  allg.  Path.,  1908,  xliii,  172. 

Firth  and  Ledingham:  Atypical  Chloroma,  Roy.  Soc.  Med.,  Proceedings,  1910,  60. 
Flohr:  Ein  Beitrag  zur  Kenntnis  der  Chloromerkrankung,  Bonn,  1912. 
Fowler:   On  the  Occurrence  of  a  Form  of  Leukemia,  etc.,  International  Clinics, 

1903,  217. 

Fukushi:   Chlorom,  Deutsch.  med.  Woch.,  1909,  xxxv,  part  11,  1816. 
Gade:  Bidrag  til  kundskaben  om  klorom,  Nord.  Med.  Arkv.,  1884,  xvi,  No.  19,  1. 
Gallemaerts:  Personal  Communication,  1922. 
Gould  and  Lewald:  Chloroma,  A  Report  of  Two  Cases,  Together  with  Rontgeno- 

logical  Findings,  Amer.  Jour.  Obstet.,  1916,  1159;  Arch.  Fed.,  1916,  417; 

Medical  Record,  1916,  757. 
Gulland  and  Goodhall:   The  Pathology  of  Lymphatic  Leukemia  and  Chloroma, 

Jour.  Path,  and  Bacteriol.,  June,  1906,  332. 
Gumbel:    Ueber  das  Chlorom  und  seine  Beziehung  zur  Leukamie,  Virchow's 

Arch.  f.  path.  Anat.,  1903,  clxxi,  504. 

Hall,  Hebb  and  Bernstein:    Chloroma,  Proceedings  Medical  Section,  Royal  So- 
ciety of  Medicine,  February  23,  1909,  157. 

Hall  and  Hebb:  Chloroma,  Brit.  Med.  Jour.,  March  6,  1909,  601. 
Harris  and  Moore:   Preparation  from  Case  of  Chloroma,  Lancet,  London,  1902, 

525. 

Hepburn:  Chloroma,  Canada.  Med.  Assoc.  Jour.,  1914,  xliii,  s.  2;  iv,  616-619. 
Herz:  Zur  Frage  der  gemischten  Leukamie,  Wien.  klin.  Wochen.,  1909,  1030. 
Heyden:  Das  Chlorom,  1904,  Inaug.  Diss.,  Rostock. 
Hillier:  Recurrent  Tumor  of  the  Orbit  Followed  by  Similar  Growths  on  the  Other 

Side  of  the  Head,  on  the  Dura  Mater  and  Under  Costal  Pleura,  Trans. 

Path.  Soc.,  London,  1855,  337. 

Hird:   Chloroma,  Birmingham  Med.  Review,  1917,  49. 
Kitchens:  Some  Remarks  on  a  Case  of  Chloroma,  Brit.  Med.  Jour.,  December  26, 

1903,  1632. 
Hochhaus:    Anatomischen  Praparate  eines  Falles  von  Chlorom,  Munch,  med. 

Woch.,  1911,  Iviii,  1271. 
Hochheim:    Ein  Beitrag  zur  Kenntnis  der  symmetrischen  Lid  und  orbital  Tu- 

moren,  Graefe's  Arch.  Ophth.,  1900,  347. 
Horing:   Ein  Beitrag  zur  Kenntnis  des  Chloroma,  Inaug.  Diss.,  Tubingen,  1891; 

also  Arb.  a.  d.  Path.  Anat.  Inst.  za  Tubingen,  1891,  part  1,  180. 
Huber:   Studien  liber  das  sogenannte  Chlorom,  Arch.  d.  Heilk.,  1878,  129. 


602  ARTHUR  J.  BEDELL 

Hudson:  A  Case  of  Chloroma,  Royal  London  Ophth.  Hospital  Report,  1910,  181. 
Jacobaeus:    Beitrage  zur  Kenntnis  der  myeloiden  Chloro-leukamien,  Deutsch. 

Arch.  f.  klin.  Med.,  1909,  7. 
Kelsch  and  Vaillard:  Tumeurs  lymphadeniques  multiples  avec  leucemie,  Annales 

de  I'lnst.  Pasteur,  iv,  276. 

King:  A  Case  of  Chloroma,  Jour.  Med.  Sc.,  Edinburgh,  August,  1853,  xvii,  97. 
Klein  and  Steinhaus:  Ueber  das  Chlorom,  Centralbl.  f.  allg.  path.  Anat.,  1904,  49. 
Koerner:   Ein  Fall  von  Chlorqm  beider  Sdilafenbeine,  etc.,  Zeitschr.  f.  Ohrenh. 

1896,  xxix,  92;  also  Arch.  Otol.,  1897,  xxvi,  289. 
Kramer  and  Birnberg:  A  Report  of  a  Case  of  Chloroma,  Jour.  Amer.  Med.  Assoc., 

June  23,  1917,  1900. 
Lang:    Monographic  du  chloroma,  Arch.  ge"n.  de.  med.,  November,  1893,  555; 

and  January,  February,  and  March,  1894,  63,  186,  313;   De  quelques  cas 

recents  de  chloroma  ou  cancer  vert.,  ibid.,  July,  August,  and  September, 

1898,  98,  207,  317. 
Lehman:    Ein  Fall  von  Chlorom,  St.  Petersburg,  med.  Wochen.,  September  7, 

1906,  411. 

Lehndorff:    Zur  Kenntnis  des  Chloroms  (Chloroleukamie,  Chloroleukosarkoma- 

tose),  Jahrb.  f.  Kinderh..  July  1,  1910,  53. 
Leighton:  Note  on  the  Demonstration  of  Eosinophile  Granulation  in  the  Cells  of 

Chloromata,  Jour.  Path,  and  Bacteriol.,  1908,  xii,  111. 
Lewis:  A  Case  of  Chloroma  Simulating  Mastoid  Disease,  Lancet,  1919,  831. 
Libman:  Discussion  Bierring's  Case,  J.  A.  M.  A.,  1912,  1436. 
Lubarsch:  Koerner's  Case,  Zeitschr.  f.  Ohrenh.,  xxxii,  129,  and  Arch.  Otol.,  1898, 

•   xxvii,  450. 

Mackenzie:  A  Practical  Treatise  on  Diseases  of  the  Eye,  Philadelphia,  1855,  128. 
Meizner:  Zur  Kenntnis  des  myeloiden  Chloroms,  Wien.  klin.  Wochen.,  May  16, 

1907,  xx,  593. 

Meller:   Die  lymphomatosen  Geschwulstbildungen  in  der  Orbita  und  im  Auge. 

Arch.  f.  Ophth.,  1905,  130. 
Merrill  and  Bedell:   Chloroma,  with  Special  Reference  to  the  Ocular  Symptoms, 

New  York  State  Jour.  Med.,  October,  1907,  393. 
Mieremet:    Ein  Klinik   unter  dem   Bilde  eines  malignen  Tumors  verlaufender 

Fall  von  myeloidschen  Chlorom,  Virchow's  Arch.  f.  path.  Anat.  u.  Physiol., 

1914,  353. 

Paltauf :  Lymphosarcom,  etc.,  Ergeb.  d.  allge.  Path.,  1896,  679. 
Pappenheim :  Die  Stellung  der  Chlorome  und  Myelome  unter  den  Tumarerkrank- 

ungen  des  hamatopoetischen  Apparats,  Folio  hsematol.,  1909,  vii,  439. 
Paulicek  and  Wutscher:    Zur  Kenntnis  des  myeloidschen  Chloroms,  Deutsch. 

med.  Wochen.,  1911,  xxxvii,  part  1,  155. 
Pearson:  Chloroma  with  Special  Reference  to  Ear,  Nose,  and  Throat  (Bierring's 

cases),  Annals  Oto.,  Rhin.  and  Laryn.,  September,  1920,  807 
Pfieffer:   Ueber  das  Chlorom  des  Schadels  ein  typisches  Krankheitsbild,  Munch. 

med.  Wochen.,  1906,  1909. 
Pinkus:    Chloroma,  Nothnagel's  Encyclopedia  of  Practical  Medicine,  Am.  Ed., 

1905,  ix,  576. 
Pissavy  and  Richet  Fils:  Etude  clinique,  hematologique  et  anatomique  d'un  cas 

de  chlorome  atypique,  Arch,  des  Maladies  de  Coeur,  1912,  v,  248. 


Chloroma  603 

Pope  and  Reynolds:  A  Case  of  Chloroma,  Lancet,  London,  May  18,  1907,  1351. 
Port  and  Schutz:    Zur  Kenntnis  des  Chloroms,  Deutsch.  Arch.  f.  klin.  Med., 

October  23,  1907,  588. 
Risel:  Zur  Kenntnis  des  Chloroms — based  on  one  of  Rosenblath's  cases,  Deutsch. 

Arch.  f.  klin.  Med.,  1901,  31. 

Rocca villa:  Chloroma  leucemico  Pathologica,  1911,  iii,  229. 
Rosenblath:  Ueber  Chlorom  und    Leukamie,    Deutsch.    Arch.   f.  klin.    Med., 

1901,  1. 
Sakaguchi:  Ueber  myeloisches  Chlorom,  Mitt.  a.  d.  kaiserlichen  Univ.  zu  Tokyo, 

1914-1915,  xiii,  197. 
Sattler:  A  Case  of  Chloroma,  Arch.  Ophth.,  1912,  452;  Amer.  Oph.  Soc.  Trans., 

1912,  214. 
Sauer:  Ein  Beitrag  zur  Kenntnis  des  Chloroms,  Virchow's  Arch.  f.  path.  Anat.  u. 

Physiol.,  1914,  341. 
Schlaugenhaufer:    Ein  Fall  von  Chloroleukamie  mit  griinem  Uterus,  Arch.  f. 

Gynakologie,  1911-12,  xcv,  1. 

Schmidt:  Ueber  einen  Fall  von  Chlorom,  Inaug.-Dissert.,  Gottingen,  1895. 
Simmonds  and  Romer:  Chlorom,  Deutsch.  med.  Woch.,  1914,  260. 
Simon:    Myeloidische  Chloroleukamie  (Chlorom)  unter  dem  Bilde  eines  malignen 

mamma  Tumors,  Berlin,  klin.  Wochen.,  1912,  xlix,  893. 
St.   Bernheimer:  •  Ueber  Lymphadenome  der  Orbita,   Beilage  bericht.  Ophth. 

Gesellschaft,  Heidelberg,  1889,  199. 
Sternberg:  Ueber  lymphatische  Leukamie,  Verhandl.  d.  Deutsch.  path.  Gesellsch., 

1903,  30;  also  Discussion  Wien.  klin.  Wochen.,  1903,  462;   Munch,  med. 

Wochen.,  1902,  126;  Wien.  klin.  Woch.,  1902,  55. 
Sternberg:    Zur  Kenntnis  des  Chloroms,  Chloromyelosarkom,  Beitr.  z.  path. 

Anat.  u.  z.  allg.  Path.,  1905,  437. 

Sutherland:  A  Case  of  Chloroma,  Scot.  Med.  and  Surg.  Jour.,  1902,  137. 
Treadgold:  Chloroma  and  Acute  Lymphatic  Leukemia  with  an  Account  of  Four 

Cases  and  a  Discussion  of  the  Pathology  of  the  Disease,  Quart.  Jour.  Med., 

April,  1908,  239. 

Tresilian:  A  Case  of  Chloroma,  Brit.  Jour.  Children's  Diseases,  1910,  536. 
Trevithick:  A  Case  of  Chloroma,  etc.,  Lancet,  July  18,  1903, 158,  a  note;  ibid., 

530. 
Turk:    Discussion — Wien.  klin.  Wochen.,   1903,  462;  Gesellsch.  f.  inn.  Med., 

December  12,  1901. 
Von  Recklinghausen :    Uber  Chlorome,  Tageblatt  der  58.  Versammlung  deut- 

scher  Naturforscher  und  Arzte,  Strasburg,  1885,  421. 
Waldstein:  Ein  Fall  von  progressiver  Anamie  u.  darauf  folgender  Leukocythamie 

mit  Knochenmarkerkrankung  und  einen  sogenannten  Chlorom,  Virchow's 

Arch.,  1883,  xci,  12. 
Walls  and  Goldsmith:  Chloroma  with  a  Report  of  a  Case  of  the  Myeloid  Variety, 

Amer.  Jour.  Med.  Sci.,  1914,  836. 
Weinberger:   Lymphoides  Chlorom  mit  allgemeiner  lymphoid  Hyperplasie,  etc  , 

Zeitschr.  f.  Heilk.,  1907,  44;  Wien.  klin.  Wochen.,  1903,  xvi,  461. 


PROPOSITIONS  FOR  CONGRESS  ACTION 


THE  VALUE  OF  LETTERS  AND  CHARACTERS  AS 
VISUAL  TESTS 

A.  E.  EWING,  M.D. 

St.  Louis,  Mo. 

Since  the  fixing  of  the  visual  angle  by  Hooke  (1674)  and  its  practical 
adaptation  by  Snellen  to  test  letters  (1862),  there  have  been  efforts 
on  the  part  of  various  investigators  to  find  an  object  or  objects  of 
universal  recognition  that  could  be  made  use  of  to  represent  this  angle 
for  the  accurate  testing  of  vision.  The  ideal  has  not  yet  been  at- 
tained. The  nearest  approach  to  its  attainment  has  been  the  employ- 
ment of  letters  from  the  alphabets  of  various  languages.  For  the 
Anglo-Saxon,  the  Latin  and  the  Teutonic  peoples  the  block  letter  was 
suggested  by  Snellen,  was  used  by  him  in  his  charts  and  has  become 
the  almost  universal  standard  in  these  countries.  Snellen  realized 
that  these  letters  offered  only  an  approximately  correct  representa- 
tion of  the  relative  visual  acuity,  even  though  certain  openings  in 
the  lines  constructing  the  letters  indicated  the  one-minute  angle,  as 
the  opening  in  the  letter  E  and  in  the  letter  C,  the  two  representative 
letters  among  those  used  for  measuring  the  vision,  the  one  being  round 
and  the  other  square. 

The  realization  that  letters  were  variable  and  faulty  in  the  attain- 
ment of  uniform  visual  results  led  to  the  suggestion  of  the  so-called 
one-minute  tests,  as  the  Landolt  "broken  ring,"  the  "interrupted 
square"  of  Jackson,  the  central  dot  of  Wolff  berg  and  the  broken  line 
test. 

The  difference  in  the  values  of  various  letters  as  visual  tests  was 
pointed  out  by  Green  in  1872,  Dennett  in  1885,  Randall  in  1894,  and 
later  by  Jackson.  When  Snellen  first  adopted  the  "block"  or 
"Egyptian  paragon"  letters  he  recognized  these  differences  and  for 
this  reason  he  selected  letters  which  would  approach  as  nearly  as 
possible  to  his  three  line,  one  and  five  minute  standard  square. 

604 


The  Value  of  Letters  and  Characters  as  Visual  Tests          605 

In  order  to  get  at  this  subject  more  definitely,  at  the  suggestion  of 
Dr.  Jackson  a  committee  was  appointed  by  the  Ophthalmic  Section 
of  the  American  Medical  Association  in  1914  on  "Standardizing  Test 
Cards."  At  the  further  suggestion  of  Dr.  Jackson,  the  members  of 
this  Committee  selected  all  the  appropriate  square  and  round  letters 
in  the  alphabet,  both  in  the  "  Egyptian  paragon  "  or  "  block  "  form  and 
in  the  "Gothic"  or  "antique"  form,  the  two  forms  in  general  use,  and 
working  separately  with  various  patients  of  all  types,  each  committee- 
man  gave  his  conclusions  as  to  the  visual  value  of  each  of  the  letters 
as  compared  with  the  Landolt  "broken  ring."  The  average  per- 
centage visual  value  of  these  results  is  shown  in  the  accompanying 
table. 

Gothic  Block 

L 0.62  F .0.81  L 0.71  P 0.81 

A 0.71  C 0.85  T 0.74  D 0.82 

T 0.72  K 0.88  V ...0.78  Z 0.84 

V 0.74  0 0.88  U 0.79  N 0.85 

H 0.74  D 0.88  C 0.79  E 0.85 

Z 0.76  X 0.91  O 0.80  R 0.88 

E 0.77  R 0.93  .       Y 0.80  S 0.89 

N 0.79  S 1.05  F 0.81  C 0.92 

P 0.79  B 1.16  H 0.92 

B 1.00 

These  results  revealed  that  few  of  the  letters  could  be  depended  on 
to  give  so-called  normal  visual  acuity  as  compared  with  the  "broken 
ring"  of  Landolt.  They  further  confirm  Snellen's  observation  that 
the  "block"  letter  was  superior  to  the  "Gothic"  letter  for  the  con- 
struction of  visual  test-types.  Also  they  standardized  so  far  as  was 
possible  the  relative  visual  value  of  each  letter. 

In  this  table  it  is  shown  that  the  letter  L  is  the  most  readily  seen 
of  any  of  the  letters  at  a  given  distance,  but  it  is  well  known  to  all 
ophthalmologists  that  persons  who  are  able  to  recognize  the'  L  have 
sufficiently  good  vision  to  pursue  any  of  the  ordinary  vocations  neces- 
sary to  the  earning  of  a  living.  In  this  lies  the  reason  why  test  letters 
are  almost  universally  employed  as  visual  tests.  In  other  words,  the 
Committee  has  demonstrated  that  persons  with  0.62  per  cent,  of  so- 
called  standard  or  normal  vision,  see  well  enough  for  all  ordinary 
purposes. 

"In  all  times  letters  and  numbers  have  been  preferentially  em- 
ployed by  ophthalmologists  in  the  investigation  of  the  power  of 
vision,"  observed  Donders  in  his  work  on  refraction  in  1864.  After 
the  lapse  of  another  half  century,  during  which  period  workers  in 


606  A.  E.  EWING 

ophthalmology  have  increased  by  thousands,  it  may  be  safely  claimed 
that  this  observation  is  now  an  axiom,  with  letters  still  in  the  ascen- 
dant. The  investigations  of  the  Committee  above  mentioned  have 
given  each  letter  a  definite  visual  value  in  comparison  with  an 
accepted  visual  standard.  Experience  has  proved  that  a  visual 
acuity  of  75  per  cent,  of  this  visual  standard  indicates  sufficiently 
good  vision  for  even  the  highest  grades  of  occupations  in  securing  a 
living.  The  army  accepted  50  per  cent,  as  sufficient  for  ordinary 
occupations,  and  practically  75  per  cent,  for  the  finest  rifle  work,  as 
the  vision  of  the  riflemen  was  taken  as  a  rule  with  Snellen  type,  and 
the  work  of  the  Committee  has  shown  that  the  visibility  of  this  type 
ranges  all  the  way  from  66  to  100. 

Another  circumstance  that  has  been  confirmed  by  experience  is, 
that  ophthalmologists  as  a  rule  consider  the  so-called  "one-minute" 
tests  as  nuisances  and  time  consumers,  and  will  not  bother  to  employ 
them  when  letters  and  characters  serve  the  purpose.  When  great 
accuracy  is  required,  or  an  exact  comparison  is  necessary,  it  is  well  to 
have  some  one  of  these  tests  at  hand. 

With  the  above  data  at  our  command  the  rational  method  of  dis- 
posing of  this  vexed  question  of  visual  acuity  would  be  to  accept,  as 
the  standard  or  normal  vision,  the  vision  measured  by  any  of  the  block 
letters  from  T  to  H  in  the  report  of  the  Committee,  when  these  letters 
are  drawn  to  the  one-  and  five-minute  scale  of  Snellen.  The  same  rule 
should  apply  to  characters  when  they  are  drawn  practically  within 
these  limits.  This  would  mean  a  variation  in  the  visibility  of  18 
points,  but  experience  has  further  demonstrated  that  this  counts  for 
little  after  the  75  point  limit  has  been  passed.  The  reading  of  any 
one  of  these  letters  should  be  considered  as  the  100  mark,  instead  of 
the  reading  of  the  broken  ring  of  Landolt,  and  visual  acuity  above 
this  standard  100  mark  should  be  indicated  as  normal  plus.  Such 
an  arrangement  would  satisfy  every  visual  requirement. 


M.  URIBE  TRONCOSO,  M.D. 
New  York  City 

It  is  a  rule  in  anatomic  descriptions  to  consider  the  subject  stand- 
ing in  front  of  the  observer,  who,  when  speaking  of  the  right  side, 
for  instance,  always  refers  to  the  subject's  right,  which  is  in  front  of 
the  observer's  left  hand.  This  is  a  basic  rule  and  all  anatomic  treat- 
ises in  the  medical  literature  of  all  countries  conform  to  it. 

The  same  rule  holds  good  in  physiology,  in  surgery  (when  not 
otherwise  specified),  in  clinical  methods  of  examination,  etc.  The 
description  of  one  operation  is  easily  understood  when  the  author 
conforms  to  the  anatomic  nomenclature  and  the  reader  can  visualize 
the  different  stages  of  the  interference  with  the  organs  as  they  really 
are  in  front  of  him.  In  this  way  the  necessary  repetition  of  "pa- 
tient's right  or  left  side"  or  "surgeon's  right  or  left"  is  avoided,  and 
medical  descriptions  will  gain  in  accuracy,  clearness,  and  conciseness. 

In  ophthalmology,  unfortunately,  the  official  anatomic  nomencla- 
ture is  not  followed  up  altogether,  with  the  resultant  misunderstand- 
ing, confusion,  and  unnecessary  mental  strain. 

Diseases  of  the  anterior  segment  of  the  eye  are  studied  in  the  text- 
books and  treatises  generally  according  to  the  anatomic  standard  be- 
cause this  is  unavoidable,  the  illustrations  necessarily  showing  the 
patient's  eye  facing  the  observer;  but  the  confusion  begins  when  the 
pathologic  sections  are  represented  inverted,  the  eye  in  the  same  posi- 
tion in  space  as  the  physician's  eye.  Passing  from  the  description  of 
the  changes  to  the  study  of  the  sections,  an  effort  of  imagination  is 
necessary  to  replace  the  organs  and  lesions  in  the  proper  position.  In 
this  way  two  different  standards  are  set  up  and  the  relation  of  the 
parts  and  structures  to  each  other  changed,  without  sufficient  reason 
or  practical  benefit. 

In  the  description  of  the  normal  and  pathologic  iris,  for  instance, 
the  membrane  is  represented  outstretched  in  front  of  the  observer, 
whereas  the  microscopic  sections  show  the  posterior  or  pigmentary 

607 


608  M.  URIBE  TRONCOSO 

layer,  forward.  When  the  ophthalmologist  is  accustomed  to  remem- 
ber the  angle  of  the  anterior  chamber,  in  the  non-anatomic  position, 
it  is  very  difficult  for  him  to  transpose  it  to  the  proper  place  if  the  new 
method  of  examination  with  the  contact  glass  and  the  ophthalmoscope 
(ophthalmogonioscopy)  is  used.  Many  competent  observers  fail  to 
grasp  the  relations  of  the  ciliary  body  with  the  anterior  chamber,  its 
continuity  with  the  sclera,  the  position  of  the  sclerocorneal  trabecu- 
lum  and  Schlemm  canal  in  relation  with  the  cornea,  etc. 

The  different  systems  of  blood-vessels  in  the  anterior  part  of  the  eye, 
easily  understood  in  the  old  schematic  figures,  become  difficult  to 
represent  in  their  true  position  with  the  patient's  eye  in  front,  particu- 
larly the  relations  of  the  perforating  ciliary  vessels  with  the  intra- 
scleral  network  and  the  iris  and  ciliary  vessels. 

In  glaucoma,  when  there  is  an  adhesion  of  the  root  of  the  iris  to  the 
cornea,  it  is  easier  to  visualize  the  formation  of  the  new  iridocorneal 
angle  and  correlate  it  with  the  diminution  in  depth  of  the  anterior 
chamber,  the  enlargement  of  the  pupil  and  its  irregular  shape  due  to 
partial  adhesion,  if  the  mental  picture  of  the  structures  has  been  made 
in  the  anatomic  position. 

The  confusion  and  misunderstanding  grow  worse  in  the  study  of  the 
optic  nerve,  optic  tracts,  decussation  in  the  chiasm  and  the  relations 
of  the  bundles  of  the  nerve-fibers  and  tract  forming  a  forked  sensorial 
organ,  with  the  two  lateral  halves  of  the  retina  and  the  visual  field. 

The  well-known  schematic  figures  of  the  optic  pathway  are  always 
printed  considering  the  observer  standing  at  the  back  of  the  patient. 
This  was  probably  made  in  order  to  facilitate  the  understanding  of  the 
visual  fields  which,  as  recorded  by  the  campimeter  and  perimeter,  are 
also  inverted  and  shown  in  the  non-anatomic  position,  as  we  will 
consider  later. 

The  transfer  and  reversal  of  the  visual  field  found  in  hemianopsia 
and  the  location  of  the  homonymous  halves  of  the  retina  to  the  proper 
side  of  the  patient  have  been  the  cause  of  the  great  obscurity,  mis- 
understanding, and  mental  effort  which  generally  confronts  the  stu- 
dent in  this  particular  subject.  Homonymous  is  taken  generally  as 
meaning  the  two  halves  of  the  same  name  in  the  retina, — for  instance, 
both  nasal  or  temporal  halves, — while  in  reality  they  refer  to  the 
patient's  right  or  left  side. 

Any  one  who  will  study  this  subject  according  to  the  anatomic 
sta'hdard  will  readily  realize  the  numerous  advantages  derived,  and  the 
facility  to  memorize  the  lesions. 


Ophthalmologic  Versus  Anatomic  Nomenclature  609 

It  is,  however,  in  the  diagnosis  of  the  troubles  of  motility  of  the  eye 
where  the  principal  difficulties  arise  for  the  student;  an  earnest  effort 
and  great  mental  strain  are  required  to  transpose  the  mental  images 
from  one  position  to  the  other.  The  anatomy  of  the  ocular  muscles  is 
taught  in  reference  to  the  observer's  eye  and  he  needs  to  memorize 
the  insertion  and  action  of  the  six  extrinsic  muscles  in  this  position. 
Afterward  in  clinical  examinations,  with  the  patient  in  front  of  him, 
either  watching  the  limitation  of  movements  of  the  eyeball  in  case  of 
paralysis  of  the  muscles,  or  when  moving  the  candle  from  one  side  to 
the  other  in  the  subjective  examination  for  diplopia,  he  will  con- 
stantly need  to  reverse  his  mental  images  or  go  back  and  place  himself 
behind  the  patient  to  be  able  to  arrive  at  a  diagnosis. 

The  excellent  Fuchs  text-book,  fifth  English  edition,  page  713, 
shows,  in  Fig.  301,  the  place  and  insertion  of  the  ocular  muscles  in  the 
inverted  position,  and  side  by  side  the  next  figure  represents  the  eye 
in  the  anatomic  way.  The  four  frozen  sections  of  the  orbit  and  the 
schematic  plan  of  the  action  of  the  muscles  after  Marquez  are  seen 
from  before,  as  are  also  the  lines  of  insertion  of  the  four  recti,  but  a 
few  pages  later,  in  the  chapter  on  paralysis,  the  inversion  reappears, 
and  although  the  student  must  detect  the  primary  and  secondary 
deviations  facing  the  patient  and  visualize  the  angle  of  deflection  and 
the  limitation  of  movement  in  the  affected  areas,  still  he  must  revert 
his  findings  to  the  common  position  for  comprehending  them. 

A  strange  contradiction  is  found  in  the  use  of  Duane's  tangent  plane 
for  plotting  the  double  images.  Although  the  observer  is  in  front  of 
the  patient  carrying  the  light  and  thrusting  pins  in  the  curtain,  and 
although  the  graduation  of  the  latter  is  turned  toward  the  observer 
and  the  marks  made  in  it  show  through,  still  he  must  consider  the 
right  and  left  side  according  to  his  own  and  not  to  the  patient's  sides. 

In  the  detection,  measurement,  and  correction  of  heterophorias  the 
same  thing  happens.  The  tests  must  be  conducted  from  before  the 
patient,  but  the  estimation  of  the  defect  and  the  thinking  is  done  from 
behind. 

For  men  who  are  accustomed  to  use  the  anatomic  nomenclature  the 
reading  in  the  text-books  of  the  chapters  on  paralysis  of  the  ocular 
muscles,  and  the  transfer  and  memorizing  of  symptoms  in  the  proper 
position,  require  a  long,  painful,  and  strained  mental  process,  which 
will  be  made  unnecessary  if  one  standard  position  both  for  objective 
and  subjective  examination  be  used  (Fig.  1). 

This  does  not  mean  that  the  observations  and  tests  upon  our  own 

*     39 


610 


M.  URIBE  TRONCOSO 


eye  should  be  entirely  discarded,  but  only  that  they  shall  constitute 
the  exception  and  not  the  rule  as  they  are  to-day.  Of  course,  many 
ophthalmologists  already  trained  in  this  school  of  double  positions, 
and  who  have  attained  the  habit  of  the  mental  processes  required  to 
make  the  inversion  quickly  and  without  effort,  will  find  it  entirely 
unnecessary  or  even  inadvisable  to  depart  from  their  habits,  but  for 
the  beginner  in  ophthalmology  to  be  taught  in  the  orthodox  way  shall 
mean  much  time  saved  and  much  effort  spared. 


Fig.  1. — Homonymous  diplopia.  The  deviation  of  the  left  eye  inward  makes 
the  image  of  the  candle  fall  at  the  inner  side  of  the  macula,  M,  and  is  projected 
outward,  where  a  false  image  is  seen  at  the  left. 


THE  INVERSION  OF  THE  VISUAL  FIELD 

The  ordinary  way  of  recording  the  visual  fields  is  to  consider  the 
findings  as  seen  from  an  observer  at  the  back  of  the  patient.  This  was 
probably  made  necessary  in  the  beginning  by  the  use  of  the  black- 
board or  campimeter,  in  which  the  limits  were  drawn  up  as  if  made 
by  the  patient's  hand.  In  this  position  the  visual  field  of  the  left  eye 
faces  the  left  side  of  the  patient  and  has  the  normal  notch  correspond- 
ing to  the  nose  downward  and  inward,  opposite  to  the  corresponding 
part  of  the  right  side  (Fig.  2). 

With  the  advent  of  the  perimeter,  however,  the  interpretation  of 
the  findings  became  more  difficult,  because  the  observer,  standing  in 


Ophthalmologic  Versus  Anatomic  Nomenclature 


611 


front  of  the  patient  and  watching  his  eye  for  a  correct  central  fixation, 
needs  to  transfer  his  findings  from  the  arc  to  a  chart  and  use  a  mental 
operation  to  determine  on  which  side  the  marking  ought  to  be  done. 
To  facilitate  the  recording  and  make  it  a  mechanical  operation  the 
self -registering  perimeter  was  devised.  In  this  instrument  the  findings 
are  marked  on  the  opposite  side  of  the  art,  upon  a  graduated  scale, 
which  has  the  same  color  of  the  figures  on  the  arc. 

The  violation  of  the  anatomic  standard  which  this  recording  of  the 
field  entailed  made  imperative  for  the  understanding  of  the  subject 
proper  orientation  of  the  oculist  to  extend  this  same  faulty  position J;o 


Uftf 


Fig.  2. — The  fields  of  vision  as  recorded  at  present. 


the  anatomy,  physiology,  and  neurology  of  the  eye,  setting  two  dif- 
ferent standards  for  the  description  of  the  organs,  lesions,  and  func- 
tions. 

The  result  of  this  great  departure  is  an  added  mental  strain  in  order 
to  transpose  the  mental  images  from  the  patient  in  front  of  the 
observer  to  the  field,  and  determine,  for  instance,  to  which  part  of  the 
retina  one  scotoma,  a  sector-like  defect,  etc.,  corresponds.  In  case  of  a 
thrombosis  of  the  superior  temporal  artery  of  the  right  retina, 
where  will  the  sector-like  defect  of  the  field  correspond?  Undoubtedly 
to  the  inferior  nasal  quadrant.  The  student  visualizing  the  ophthal- 
moscopic  lesion  and  wishing  to  represent  to  himself  the  defect  on  the 


612 


M.  URIBE  TRONCOSO 


field  needs  to  transfer  the  lesion  first  to  his  own  eye  and  then  find  the 
normal  inversion  in  the  field  and  locate  the  defect. 

The  understanding  of  certain  complicated  lesions  in  the  brain  and 
the  impairment  of  the  functions  they  produce  are  more  difficult  to 
visualize  with  the  present  standard. 

As  we  have  pointed  out*  before,  in  case  of  hemianopsia  the  correla- 


Fig.  3. — Schematic  representation  of  the  optic  pathway  s,  fields  of  vision  on 
both  sides  as  projected  in  the  space  in  front  of  the  observer,  and  records  of  the 
fields  in  the  anatomic  position. 

tion  of  the  blind  sides  of  the  retinae  with  the  visual  fields  and  the 
patient's  right  or  left  is  very  difficult. 

If  a  lesion  is  present  in  the  left  optic  tract,  the  text-book  tells  the 
student  that  the  left  halves  of  both  retinse  shall  be  wanting;  the 
patient  will  see  only  the  left  halves  of  all  objects.  In  the  clinic  the 
patient  is  facing  us  and  explaining  which  side  of  the  objects  he  sees; 


Ophthalmologic  Versus  Anatomic  Nomenclature  613 

by  the  perimetric  examination  we  shall  determine  that  the  temporal 
field  in  the  right  eye  of  the  patient  and  the  nasal  field  of  the  left  are 
wanting,  still  we  must  record  the  defect  referring  all  these  symptoms 
to  our  own  eye  and  make  the  diagnosis  by  ascertaining  which  side  of 
the  objects  our  hemianopic  eye  would  see,  then  we  will  call  the  hemi- 
anopsia  right  or  left  sided. 

Would  it  not  be  easier  to  follow  the  anatomic  rules  and  record  the 
fields  as  projected  into  the  space  in  front  of  the  subject,  the  right  field 
in  front  of  his  right  eye  and  the  left  before  his  left?  (Fig.  3.)  We 
would  look  at  them  as  we  see  the  fundus,  as  we  really  found  them 
when  moving  the  test  object  upon  the  arc  of  the  perimeter. 

In  this  way  the  transfer  to  our  own  eye  will  be  useless  and  no  mental 
operations  shall  be  necessary  to  visualize  the  field  as  located  in  space. 

This  new  method  has  many  advantages:  In  the  first  place,  the  un- 
derstanding of  the  normal  retinal  projection  with  the  field  mapped 
out  in  space,  in  the  opposite  side  of  the  retina,  and  the  difference 
between  the  size  of  the  temporal  and  nasal  sides  of  the  field,  is  made 
much  easier.  The  extension  farther  forward  of  the  sensitive  portion 
of  the  retina  on  the  nasal  side,  and  the  crossing  of  the  limiting  rays  in 
the  nodal  point  of  the  eye,  can  be  demonstrated  more  clearly. 

The  localization  of  the  blind  spot  and  paracentral  scotomas  in  rela- 
tion with  the  visual  axis  is  much  easier  to  understand,  as  we  are  more 
accustomed  to  visualize  the  relations  of  the  disc  and  the  macula  in  the 
fundus  with  the  ophthalmoscope. 

The  reference  of  the  ophthalmoscopic  and  neurologic  lesions  to  the 
sides  and  places  in  the  fields  are  greatly  simplified  by  one  physiologic 
inversion  only  instead  of  the  two  now  in  use. 

There  are  no  technical  difficulties  in  the  change  from  the  old  to  the 
new  anatomic  standard.  The  ordinary  campimeter  can  be  made  of 
cloth  instead  of  board,  and  with  a  graduation  in  the  back  which  will 
allow,  by  thrusting  pins,  .the  reading  of  the  extent  of  the  field  in 
front  of  the  patient. 

The  Bjerrum  screen,  as  now  made,  will  be  more  easily  used,  no 
transfer  of  the  readings  in  the  back  to  the  present  unanatomic 
standard  being  necessary;  this  transfer  and  also  recording  from  the 
campimeter  being  a  real  difficulty  for  the  beginner. 

With  the  perimeter  the  only  changes  will  be  first  to  print  the  same 
schema  now  in  use  not  exactly  inverted  but  as  seen  by  translucency ; 
the  temporal  side  in  front  of  the  temporal  side  of  the  patient's  orbit 
in  each  side,  and  the  nasal  side  before  the  nasal  side  of  the  orbits 
(Fig.  4). 


614 


M.  URIBE  TRONCOSO 


The  positions  of  the  test-carrier  in  the  arc  shall  be  marked  on  the 
same  side  of  the  recording  scale,  the  temporal  findings  in  the  temporal 
side  of  the  scale,  and  so  on. 

In  order  to  avoid  the  confusion  which  in  the  beginning  falls  to  the 
lot  of  any  change,  the  charts  will  be  left  as  they  are  now,  only  printing 
on  the  back  another  schema,  with  the  graduation  and  limits  as  seen  by 
translucency.  A  short  direction  printed  in  them  will  direct  the 
operator  to  pencil  the  markings  in  the  same  side  of  the  graduated 
scale ;  temporal  side  of  arc  on  outer  part  of  the  scale,  nasal  on  inner 
side. 


-Ki&tEy 


•17  « 

tftr  -tXAt^cavriii-  on  The  1 


fide,  of 


Fig.  4. — The  fields  of  vision  as  recorded  in  the-anatomic  position. 

The  above  reasons  and  the  numerous  advantages  to  be  derived 
from  a  change  in  the  present  position  and  in  the  field  of  vision  afford 
us  the  opportunity  and  honor  of  submitting  to  the  International 
Congress  of  Ophthalmology  of  Washington,  D.  C.,  the  following 
proposition : 

The  International  Congress  of  Ophthalmology,  held  in  Washington, 
U.  S.  A.,  recommends  to  the  authors  and  editors  of  books  and  essays 
dealing  with  ophthalmology  to  adhere  faithfully  to  the  anatomic 
nomenclature,  and  always  consider  the  subject  standing  or  lying 
down  in  front  of  the  observer,  his  right  side  facing  the  left  hand  of  the 
latter. 

This  rule  to  be  applied  both  to  objective  and  subjective  examina- 
tions of  the  eye  and  also  to  the  visual  field. 


STANDARDIZATION  OF  PERIMETRIC  TECHNIC 

LUTHER  C.  PETER,  M.D. 

Philadelphia 

The  variable  elements  in  field  taking  can  be  included  in  two  groups : 
First,  those  which  are  correctable  and  due  to  a  lack  of  care  on  the 
part  of  the  operator,  on  the  part  of  the  patient,  or  to  inadequacy  of 
the  necessary  equipment;  and,  second,  those  which  tend  to  yield 
variable  results  from  day  to  day  because  of  organic  or  functional 
changes  in  the  visual  pathway. 

By  perimetric  study  we  endeavor  to  uncover  the  latter  group  for 
correlation  with  other  symptoms.  In  order,  however,  to  be  of  de- 
pendable value,  the  errors  of  the  first  group  must  be  eliminated.  To 
this  end  efforts  have  been  made  from  time  to  time  to  develop  a 
technic  which  can  be  made  uniform,  or  approximately  so,  through- 
out the  world,  or  wherever  perimetry  is  practised.  Notwithstanding 
these  efforts  the  frequent  mention  in  literature  of  the  need  of  stan- 
dards in  our  methods,  and  of  urgent  appeals  by  individuals  for  uni- 
formity, the  first  group  of  variable  factors  continues  to  rob  field 
studies  of  their  real  value,  although  these  errors  can,  for  the  most  part, 
be  eliminated. 

In  order,  therefore,  to  approach  this  subject  from  an  international 
standpoint,  and  to  secure  the  co-operation  of  ophthalmologists  from 
the  countries  here  represented,  the  following  resolution  is  respectfully 
submitted : 

Resolved,  That  a  Committee  be  appointed  by  the  President  of  this 
Congress  of  Ophthalmology  now  assembled,  to  consider  and  to  recom- 
mend to  this  Congress,  before  its  close,  a  standard  in  technic  which 
may  be  applicable  in  any  part  of  the  civilized  world.  « 

First:  With  reference  to  the  designation  of  the  test  objects  or 
stimuli  in  degrees,  minutes,  or  seconds. 

Second:  The  designation  of  the  pigments,  or  papers,  to  be  em- 
ployed as  colored  stimuli  in  definite  and  understandable  language,  by 
which  they  can  be  reproduced  by  the  manufacturers  of  perimetric 
instruments. 

615 


616  LUTHER  C.  PETER 

Third:  Uniformity  in  charts. 

Fourth :  A  standard  method  of  illumination. 

Fifth :  A  method  by  which  pre-exposure  and  surrounding  field  may 
be  applied  to  perimetric  studies. 

Sixth :  The  use  of  instruments  in  field  studies  with  special  reference 
to  the  needs  of  the  case. 

Seventh:  Other  recommendations  which,  in  the  judgment  of  the 
Committee,  may  seem  advisable  at  this  time. 


PROF.  S.  E.  WHITNALL 
McGill  University,  Montreal 

The  points  briefly  described  in  the  address  were  illustrated  by  lantern  slides 
of  figures  from  various  text-books  compared  with  photographs  of  actual  dissec- 
tions. It  is  not  feasible  to  reproduce  them  here,  but  the  figures  are  referred  to  in 
the  text,  and  the  photographs  will  be  found  in  the  writer's  recent  work  on  the 
anatomy  of  this  region. 

A  comparison  of  the  figures  and  descriptions  of  certain  features  in 
the  eyelids,  lacrimal  apparatus,  and  orbital  muscles,  as  given  in  the 
current  anatomic  text-books  and  copied  thence  into  special  ophthal- 
mologic  works,  with  what  may  easily  be  shown  by  dissection  to  be  the 
actual  formations,  shows  that  some  revision  of  the  subject  is  called  for. 
In  addition,  a  general  acceptance  of  one  term  instead  of  the  vicarious 
application  of  several  names  to  the  same  structure  may  well  be  urged. 

The  following  points  in  particular  seem  worthy  of  notice ;  they  are 
put  forward  in  no  hostile  criticism  of  our  text-books,  but  as  the 
writer's  experience  in  dissection  of  a  considerable  number  of  orbits. 

(1)  The  ligaments  by  means  of  which  the  conjoint  extremities  of  the 
tarsal  plates  of  the  eyelids  are  attached  to  the  orbital  margin  are 
referred  to  in  the  texts  by  various  names,  and  are  not  accurately 
described.  They  should  properly  be  called  TARSAL  LIGAMENTS, 
medial  and  lateral,  since  the  term  "palpebral"  in  connection  with 
such  composite  structures  as  the  eyelids  is  somewhat  indefinite;  the 
expression  "palpebral  ligament,"  moreover,  has  been  applied  by  some 
authors  to  the  septum  orbitale. 

The  MEDIAL  TARSAL  LIGAMENT  (the  ligamentum  palpebrale 
mediale  of  the  B.N.A.  terminology,  also  known  as  the  tendo  oculi 
internus,  orbicular  tendon,  internal  palpebral  or  tarsal  ligament)  is 
always  illustrated  as  a  band  with  well-defined  upper  and  lower  mar- 
gins, crossing  over  the  middle  of  a  bulging  lacrimal  sac  on  its  way  to 
gain  attachment  to  the  anterior  lacrimal  crest  and  frontal  process  of 

617 


618  S.  E.  WHITNALL 

the  maxilla,  as  in  Gray,  Fig.  938;  Fuchs,  Fig.  285;  Cunningham's 
Text-book,  Fig.  699,  and  Practical  Manual,  vol.  iii,  Fig.  7;  Piersol, 
Fig.  1199;  Sappey,  vol.  iii,  Fig.  665;  Merkel,  Fig.  38;  Spalteholz 
Atlas,  Fig.  929;  Sobotta-McMurrich  Atlas,  Fig.  763;  and  Testut, 
vol.  iii,  Fig.  494,  which  is  reproduced  in  many  books. 

Actually,  the  medial  tarsal  ligament  forms  a  complete  anterior  cov- 
ering to  the  whole  of  the  upper  half  of  the  lacrimal  sac.  Superiorly  it 
is  thin  and  spreads  out  to  blend  with  the  periosteum  of  the  bone,  so 
that  any  definition  of  an  upper  margin  appears  to  the  writer  quite 
artificial;  this  fact  can  easily  be  verified  by  removal  of  the  skin  over 
the  medial  commissure  of  the  eyelids,  and  then  dissecting  away  the 
fibers  of  the  orbicularis  oculi  muscle  which  arise  from  the  face  of  the 
ligament.  Inferiorly,  however,  the  ligament  does  present  a  con- 
spicuously free  and  thick  lower  margin;  this  edge  lies  on  a  more  an- 
terior plane  than  the  rest  of  the  somewhat  obliquely  disposed  liga- 
ment, and  is  denude  of  muscle  fibers,  facts  which  account  for  its 
prominence  beneath  the  skin  in  the  living,  and  its  accentuation  by 
lateral  traction  of  the  eyelids.  Satisfactory  definition  of  a  posterior 
or  reflected  portion  of  this  ligament,  passing  behind  the  lacrimal  sac 
(as  figured  by  Testut,  vol.  i,  Fig.  697;  Poirier,  Fig.  685;  Sobotta, 
Fig.  763),  is  difficult;  it  is  very  thin  and  appears  of  quite  secondary 
importance,  being  merely  the  fascia  clothing  the  front  of  the  pars 
lacrimalis  muscle.  Sometimes  it  is  apparently  confused  with  the 
lacrimal  fascia  (vide  infra).  .  [ 

The  terms  LATERAL  TARSAL  or  PALPEBRAL  LIGAMENT  (tendo  oculi 
externus,  ligamentum  canthi  externum)  and  RAPHE  PALPEBEALIS 
LATERALIS  (B.N.A.)  are  variously  and  confusedly  applied,  both  in 
text  and  illustration,  to  two  entirely  different  and  separate  structures, 
of  which  only  the  one  or  the  other  is  recognized,  whereas  both  are 
actually  demonstrable.  Extending  between  the  lateral  canthus  of  the 
eyelids  and  the  orbital  margin  there  is  an  actual  RAPHE,  formed  by  the 
interlacing  fibers  of  the  palpebral  portion  of  the  orbicularis  oculi 
muscle  and  strengthened  upon  its  deeper  aspect  by  the  fascial  septum 
orbitale,  but  it  passes  superficial  to  the  orbital  margin  and  is  only 
adherent  to  the  bone  by  connective  tissue.  On  cutting  through  this 
raphe,  »the  tarsal  plates,  though  more  movable,  will  be  found  still 
attached  to  bone  by  a  deeper  lying,  much  stronger  and  more  definite 
band  of  connective-tissue  fibers,  which  is  the  true  lateral  tarsal  LIGA- 
MENT. It  is  separated  from  the  superficially  lying  raphe  by  a  narrow 
but  usually  definite  cleft,  in  which  there  may  be  present  a  few  lobules 


Some  Descriptive  Errors  in  Anatomy  of  Orbit  619 

prolonged  downward  from  the  lacrimal  gland ;  and  its  actual  attach- 
ment is  just  within  the  orbital  margin,  onto  the  orbital  tubercle  of  the 
zygomatic  bone.  Some  books  figure  the  muscular  raphe  correctly  in 
one  place,  but  misapply  the  name  to  what  is  evidently  the  ligament  in 
another;  they  also  show  the  ligament  as  passing,  like  the  raphe, 
superficial  to  the  orbital  margin  instead  of  within  or  posterior  to  it 
(compare  Figs.  340  and  929  in  Spalteholz).  Both  structures  are  illus- 
trated in  Piersol,  Figs.  500  and  1199,  but  the  text  denies  the  existence 
Of  the  ligament  on  p.  484.  Cunningham  misapplies  the  terms  in  the 
text-book,  Fig.  699,  and  practical  manual,  vol.  iii,  Fig.  7;  as  does  also 
Sobotta,  Fig.  763.  Fuchs  alone  describes  both  correctly  (p.  650). 

With  further  reference  to  the  TARSAL  PLATES,  it  may  be  noted  as  an 
example  of  the  longevity  of  anatomic  descriptive  errors  that  the  term 
"tarsal  cartilage"  still  occasionally  persists  (Young's  Handbook,  fifth 
edition,  p.  373;  Howe,  vol.  i,  pp.  15  and  16);  though  C.  Krause 
pointed  out  as  long  ago  as  1842  that  no  cartilage  cells  are  present.  In 
spite  of  the  firm  consistency  of  these  plates,  the  most  striking  feature 
seen  in  microscopic  sections  is  the  relatively  enormous  size  of  the  con- 
tained tarsal  or  meibomian  glands ;  indeed,  there  appears  more  gland- 
ular formation  present  than  supporting  connective-tissue  framework. 

As  further  terminologic  inexactitudes  it  may  be  noted  that  the 
"glandulae  mucosse  Krausei"  of  the  B.N.A.  are  not  mucous  glands, 
but  are  accessory  lacrimal  glands  of  the  conjunctiva.  Also  that  Zeis, 
who  apparently  first  described  in  1835  the  sebaceous  glands  of  the  eye- 
lid margins  known  by  his  name,  spelled  the  latter  as  above,  and  not, 
as  generally  given,  Zeiss. 

(2)  The  LACRIMAL  FASCIA  (fascia  lacrimalis)  is  an  extension  of  the 
periosteal  (periorbital)  lining  of  the  medial  wall  of  the  orbit  which  passes 
from  the  posterior  to  the  anterior  lacrimal  crest,  bridging  over  com- 
pletely the  lacrimal  fossa  or  groove  with  its  contained  lacrimal  sac.  Its 
presence  must  surely  be  well  recognized  by  and  be  of  interest  to  the 
practising  ophthalmologist,  yet  the  writer  has  found  no  figure  and  but 
rare  mention  of  it  in  the  books,  and  even  then  it  is  referred  to  by  such 
misleading  terms  as  the  "deep"  or  even  "palpebral"  fascia  (e.  g., 
Schaeffer,  p.  249) ;  sometimes  it  appears  to  be  confused  with  the  deep  or 
reflected  lamella  of  the  medial  tarsal  ligament  (Toldt,  Fig.  1393;  Morris, 
p.  1106;  Fuchs,  Fig.  284).  It  is  a  strong  definite  layer  of  fibrous 
tissue,  and  forms  the  immediate  lateral  and  complete  covering  of  the 
lacrimal  sac;  it  is  pierced  by  the  lacrimal  canaliculi  and  blood- 
vessels. Occasionally  the  fascia  is  adherent  to  the  sac,  but  it  can 


620  S.  E.  WHITNALL 

usually  be  incised  separately  in  gaining  entrance  to  the  lumen  of  the 
latter;  failure  to  realize  this  point  in  passing  a  probe  commonly  leads 
the  student  in  the  dissecting  room  to  force  the  instrument  downward 
between  the  incised  fascial  covering  and  the  unopened  sac,  and  nat- 
urally a  difficulty  is  experienced  in  reaching  the  nasal  cavity.  The 
extent  and  attachments  of  the  fascia  and  the  manner  in  which  it  com- 
pletely roofs  over  the  fossa  can  best  be  demonstrated  by  dissecting  out 
the  entire  nasolacrimal  duct  and  lacrimal  sac  from  the  nasal  side; 
that  is,  by  cutting  away  the  medial  bony  walls  of  these  passages  by 
appropriate  working  from  the  inside  of  the  lateral  wall  of  the  nasal 
cavity  in  a  sectioned  head  (as  illustrated  by  Schaeffer,  Fig.  175). 
After  severing  the  lacrimal  canaliculi  and  freeing  the  fundus  of  the 
sac,  the  entire  tube  formed  by  the  sac  and  duct  can  be  lifted  out  from 
the  excavation  in  one  piece;  and  removal  of  the  whole  contents  of 
the  orbit  with  detachment  of  the  eyelids  on  the  opposite  or  orbital 
side  of  the  preparation  will  leave  the  lacrimal  fascia  as  a  complete 
entity,  exposed  on  both  sides. 

(3)  The  PARS  LACEIMALIS  MUSCLE  (the  muscle  of  Horner,  1824, 
but  chronologically  more  correctly  designated  as  that  of  Duverney, 
who  previously  described  it  in  1749,  and  well  named  it  the  tensor 
tarsi;  it  is  also  known  as  the  posterior  lacrimal  muscle).  The  books 
nearly  all  follow  the  account  given  by  Horner,  who  described  the 
muscle  as  passing  from  its  origin  on  the  lacrimal  bone  forward  and  out- 
ward to  divide  and  terminate  near  the  puncta  lacrymalia  of  the  eye- 
lids (e.  g.,  Morris,  p.  391;  Testut,  vol.  i,  p.  732;  Howe,  vol.  i,  p.  51, 
calls  it  a  "supernumerary"  muscle,  and  gives  an  insertion  into  the 
conjunctiva).  The  customary  method  of  displaying  it  is  from  behind, 
by  dissecting  both  eyelids  away  from  the  front  of  the  eyeball  and 
turning  them  nasalward,  as  depicted  in  Gray,  Fig.  520;  Piersol,  Fig. 
500;  Sobotta,  Fig.  261,  and  in  Homer's  original  figure;  so  viewed,  the 
pars  lacrimalis  fibers  of  the  orbicularis  oculi  certainly  appear  to  end  as 
described  near  the  lacrimal  puncta.  If,  however,  the  tarsal  plates  be 
now  dissected  away  (as  shown,  for  example,  in  Spalteholz,  Fig.  340), 
it  will  be  realized  that  whilst  some  of  the  muscle  fibers  are  short  and 
do  end  on  the  canaliculi  and  tarsal  plates,  yet  the  bulk  of  them  are 
continued  on  across  the  front  face  of  the  plates  as  far  laterally  as  the 
lateral  raphe.  In  other  words,  the  pars  lacrimalis  or  Horner's  muscle 
appears  to  the  writer  to  denote  merely  the  conjoint  ends  of  two  con- 
tinuous long  muscle  bands  (the  pretarsal  part  of  the  pars  palpebralis 
of  the  orbicularis  oculi)  which  sweep  across  the  eyelids  from  one  side 


Some  Descriptive  Errors  in  Anatomy  of  Orbit  '621 

to  the  other,  lying  in  front  of  and  closely  applied  to  the  tarsal  plates. 
They  can  thus  serve  far  better  to  keep  the  latter  curved  and  approxi- 
mated in  their  whole  length  to  the  eyeball  under  all  its  movements, 
than  if  they  were  merely  inserted  into  the  medial  ends  of  the  plates. 
The  continuity  of  the  fibers  and  their  passage  at  the  medial  end 
behind  the  lacrimal  sac  would  explain  why  removal  of  the  medial 
tarsal  ligament  in  ablation  of  the  lacrimal  sac  does  not  necessarily 
entail  ectropion  of  the  lower  lid,  as  suggested  by  the  writer  in  a  paper  in 
"The  Ophthalmoscope,"  April,  1913.  It  may  be  noted  that  the  liga- 
ment passes  across  the  front  of  the  upper  half  of  the  lacrimal  sac, 
whilst  the  pars  lacrimalis  muscle  passes  behind  its  upper  half,  so  that 
the  two  form  a  complete  hood  over  the  fundus  of  the  sac.  The  lower 
half  of  the  sac  is  related  to  the  orbital  fat  behind,  and  is  merely  cov- 
ered in  front  by  septum  orbitale,  orbicularis  oculi  muscle,  and  skin. 

(4)  The  shape  of  the  normal  LACRIMAL  SAC  appears,  according  to 
the  writer's  findings,  wrongly  represented  in  every  instance.  In  all 
the  figures  enumerated  in  reference  to  the  medial  tarsal  ligament  in  the 
first  part  of  this  article,  the  sac  is  drawn  as  seen  from  the  front  in  the 
form  of  the  bulging  or  dilated  upper  end  of  the  nasolacrimal  duct. 
Possibly  this  is  due  to  the  exigences  of  pictorial  representation,  though 
it  is  also  so  described  in  some  texts  (e.  g.,  Quain,  Schaeffer,  Sobotta). 
Actually  the  sac  conforms  in  shape  to  the  bony  fossa  or  groove  in 
which  it  lies,  and  tapers  off  above,  though  its  anteroposterior  diameter 
in  its  middle  may  exceed  that  of  the  duct  below.  The  shape  of  the 
whole  tube,  lacrimal  sac  and  nasolacrimal  duct  together,  may  be 
likened  to  the  end  of  a  quill-pen  seen  sideways,  a  configuration  that 
the  writer  has  always  found,  especially  in  formalin  hardened  dissec- 
tions prepared  as  described  above  with  reference  to  the  lacrimal  fascia, 
and  as  is  shown  by  Aubaret's  series  of  isolated  lacrimal  sacs,  and  in 
the  casts  made  by  Zabel.  Toldt's  Fig.  1393  shows  well  the  narrow 
transverse  lumen  of  the  sac  in  section,  and  will  enable  one  to  realize 
that  any  action  which  the  fibers  of  the  orbicularis  oculi  muscle  may 
have  upon  it  in  the  act  of  winking  must  be  transmitted  through  the 
agency  of  the  covering  lacrimal  fascia,  and  will  tend  to  dilate  the  sac, 
which  is  possible  from  its  collapsed  condition  (and,  as  indeed  Scimemi 
proved  experimentally)  rather  than  to  compress  it,  which  does  not 
appear  possible  either  from  its  position  or  its  condition. 

(5)  The  LEVATOR  PALPEBR^D  SUPERIORIS  MUSCLE  is  oftentimes 
described  as  having  a  threefold  insertion  into  the  upper  eyelid, 
namely  to  the  skin,  the  tarsal  plate  and  the  conjunctiva,  but  it  is 


622  S.  E.  WHITNALL 

misleading  to  depict  all  three  insertions  as  being  of  equal  importance 
(e.  g.,  Cunningham's  Practical  Manual,  Fig.  8  and  p.  26).  The 
primary  and  essential  attachment  is  to  the  skin,  through  the  agency 
of  the  splayed  out  anterior  margin  of  the  expanded  aponeurosis  in 
which  the  muscle  belly  ends.  The  tarsal  attachment  is  effected  by 
the  agency  of  the  involuntary  superior  tarsal  or  palpebral  muscle  of 
Miiller,  which,  though  in  close  contact  with  the  under  surface  of  the 
aponeurosis  and  springing  like  it  from  the  fore  end  of  the  belly  of  the 
muscle,  does  not  "largely  form  part  of  it"  (Piersol,  p.  502);  it  is  an 
extremely  interesting  little  muscle,  from  a  clinical  standpoint  as  well 
as  from  a  morphologic  one,  since  its  tone  may  be  strikingly  responsive 
to  the  state  of  the  sympathetic  nervous  system  by  means  of  which  it  is 
supplied;  and  it  may  indicate  by  a  slight  drooping  of  the  eyelid  a 
condition  of  malaise  (as  is  well  seen  in  children)  or  of  mental  fatigue 
beyond  the  power  of  the  will  to  counteract.  The  third  so-called  inser- 
tion of  the  levator  is  merely  the  attachment  of  its  fascial  sheath, 
fused  with  that  of  the  subjacent  superior  rectus  muscle  and  void  of 
striated  muscle  fibers,  to  the  superior  conjunctival  fornix.  Its  action 
is  to  pull  this  conjunctival  fold  upwards  in  harmony  with  movement 
of  the  cornea  in  the  corresponding  direction,  and  it  might  more 
fittingly  be  described  as  an  additional  "insertion"  of  the  superior 
rectus,  comparable  to  the  similar  fascial  slips  derived  from  the  sheaths 
of  the  other  recti  muscles  which  pass  to  the  conjunctival  fornix  below, 
lateral,  and  medial  to  the  eyeball.  Most  of  the  illustrations  give  a 
complicated  and  indefinite  view  of  these  insertions;  Spalteholz,  Fig. 
923,  is  the  clearest. 

Lastly,  in  descriptions  of  the  levator,  the  osseous  attachments  of  the 
lateral  extremities  or  horns  of  the  aponeurosis  surely  deserve  more 
notice  than  they  generally  receive;  the  especial  strength  of  the  lateral 
horn,  its  enfolding  by  the  lacrimal  gland,  and  its  strong  fixation  to  the 
orbital  tubercle  of  the  zygomatic  bone  might  well  be  mentioned. 

(6)  The  LACRIMAL  GLAND  is  described  as  being  enclosed  in  a  definite 
capsule  (e.  g.,  Poirier,  vol.  iii,  p.  1122;  Morris,  pp.  1106  and  1113), 
but  the  writer  has  never  been  able  to  satisfy  himself  as  to  the  existence 
of  such  a  structure.  The  lobules  of  the  gland  are  bound  together  by  a 
connective  tissue  stroma  which  is  certainly  continuous  behind  with 
the  interlobular  fascia  of  the  orbital  fat;  it  is  slightly  more  abundant 
upon  the  surface  of  the  gland,  where  a  delicate  tissue  can  be  picked  off 
piecemeal,  but  such  formation  can  hardly  be  considered  as  a  "  capsule  " 
in  the  usual  acceptance  of  the  term.  Nor  can  "  suspensory  ligaments  " 


Some  Descriptive  Errors  in  Anatomy  of  Orbit  623 

be  satisfactorily  demonstrated.  The  gland  is  kept  in  place  by  the  eye- 
ball below  and  medially,  by  the  orbital  fat  behind,  but  chiefly  by  the 
fact,  usually  not  mentioned,  that  it  is  cut  deeply  into  and  so  partly 
subdivided  into  its  two  lobes  (orbital  and  palpebral  portions)  by  the 
lateral  horn  of  the  aponeurosis  of  the  levator  palpebrae  superioris 
muscle;  it  is,  as  it  were,  folded  round  the  lateral  part  of  the  aponeuro- 
sis, and  may  possibly  participate  to  some  extent  in  its  movements. 

(7)  The  LATERAL  RECTUS  MUSCLE  of  the  eyeball  is  commonly  de- 
scribed as  arising  by  "two  heads"  from  the  annulus  communis  of 
Zinn  at  the  apex  of  the  orbit,  and  certain  nerves  are  described  as 
entering  the  orbit  between  them.    The  statement  conveys  an  exag- 
gerated idea  of  the  muscle  origin,  reflected  in  the  figures  where  two 
definite  and  separate  heads  are  depicted  (e.  g.,  Gray,  Fig.  933;  Cun- 
ningham's Practical  Manual,  vol.  iii,  Fig.  96).    The  muscle  certainly 
arises  from  that  part  of  the  annulus  which  crosses  the  superior  orbital 
fissure,  but,  as  D wight  points  out  (p.  96),  there  is  no  break  in  the 
continuity  of  the  annular  origin  of  the  muscle  fibers,  such  as  the 
expression  "two  heads"  denotes.    The  term  is  probably  a  subversion 
of  Merkel's  description  of  one  head  arising  from  the  annulus  and 
another  from  the  spina  recti  lateralis  of  the  sphenoidal  apex  of  the 
lateral  orbital  wall;  he  shows  these  two  origins  clearly  (Fig.  28),  as 
does  Spalteholz  (Fig.  916),  but  they  do  not  span  the  superior  orbital 
fissure,  no  structures  enter  the  orbit  through  them,  and  they  are  not 
the  same  "heads"  as  described  in  later  works.    Merkel  described  the 
nerves  which  here  enter  the  orbit  as  traversing  an  "oculomotor 
foramen,"  which  is  a  definite  fibrous  ring  formed  between  the  annular 
origin  of  the  lateral  rectus  muscle  and  the  optic  nerve.    The  position 
of  the  nerves  (the  oculomotor  in  two  divisions,  the  nasociliary  and  the 
abducent)  relative  to  one  another  at  this  point  receives  unwarrantable 
stress  in  the  text-books  (e.  g.,  Buchanan,  p.  1149),  since  they  are  all 
crowded  together  and  compactly  fill  a  space  not  more  than  three  milli- 
meters in  diameter.    It  would  appear  better  to  describe  these  nerves 
as  entering  the  orbit  through  either  the  oculomotor  foramen,  or  be- 
tween the  lateral  rectus  muscle  and  the  optic  nerve  (as  does  Sobotta), 
or  within  the  cone  of  recti  muscles  which  arise  from  the  annulus,  since 
the  practical  point  is  that  the  trochlear,  frontal,  and  lacrimal  nerves 
enter  outside  the  cone  of  muscles. 

(8)  The  FASCIA  BTJLBI  (Tenon's  capsule)  will  lose  much  of  its 
descriptive  complexity  if  simply  regarded  as  the  primary  socket  of  the 
eyeball,  fused  with  the  f ascial  sheaths  of  the  muscles  where  they  pierce 


624  S.  E.  WHITNALL 

it.  The  elaborate  description  of  Motais  (followed  by  Maddox  and 
Howe,  and  formerly  included,  but  now  replaced,  in  Poirier's  Anatomy) 
forces  one  to  agree  with  D wight  that  the  "  complications  of  this  mem- 
brane are  limited  only  by  the  perverted  ingenuity  of  those  who  de- 
scribe it."  The  thickening  of  the  capsule  below  to  form  Lockwood's 
ligament,  and  the  peripheral  expansions  of  the  muscle  sheaths  to 
form  "check  ligaments"  are  easily  demonstrable,  but  the  formation  of 
"pulley-bars"  at  the  points  of  junction  of  the  muscle  sheaths  with 
the  capsule  to  prevent  compression  of  the  eyeball  in  contraction  of  the 
recti  (Fisher,  Fig.  14;  Morris,  p.  1107;  Cunningham's  Practical 
Manual,  vol.  iii,  p.  260)  is  surely  uncalled  for  if  one  considers  the  ab- 
sence of  angle  or  even  curve  in  the  run  of  a  muscle  at  such  point, 
together  with  the  extreme  mobility  of  the  eyeball.  The  writer  cannot 
find  evidence  that  the  capsule  is  continuous  behind  with  any  pro- 
longation around  the  optic  nerve,  or  that  the  interfascial  space  of 
Tenon,  which  separates  the  capsule  from  the  eyeball,  is  continuous 
with  the  so-called  supravaginal  space  along  the  nerve,  as  depicted  in 
Piersol,  Fig.  800,  and  elsewhere  described.  The  eyeball  cannot  move 
freely  within  the  capsule,  as  it  is  sometimes  stated  to  do  (Morris,  p. 
1107;  Cunningham's  Practical  Manual,  vol.  iii,  p.  259;  Buchanan, 
p.  1151);  there  can  be  only  limited  movement  between  them,  and 
both  work  together  on  the  bed  of  orbital  fat,  as  is  agreed  by  Dwight, 
Fisher,  and,  indeed,  by  Motais.  The  point  might  be  illustrated  by 
comparing  the  capsule  to  a  closely  fitting  woolen  shirt,  tightly  but- 
toned round  the  neck  (the  sclero-corneal  junction)  and  at  the  ends  of 
the  sleeves  (the  muscle  sheaths),  and  so  allowing  no  really  free  move- 
ment of  the  body  ensheathed  by  it. 

BIBLIOGRAPHY 

Aubaret:  Bibliographic  Anatomique,  1910,  xx,  i,  p.  97. 
Buchanan:  Manual  of  Anatomy,  Third  Edition,  Macmillan,  Toronto,  1916. 
Cunningham:  Textbook  of  Anatomy,  Fourth  Edition,  Frowde,  1913;  and  Manual 

of  Practical  Anatomy,  Seventh  Edition,  1920. 
Dwight:  Article  in  Norris  and  Oliver's  System  of  Diseases  of  the  Eye,  Lippincott, 

1900. 

Fisher:  Ophthalmological  Anatomy,  London,  1904. 

Fuchs:  Textbook  of  Ophthalmology,  Duane's  Fifth  Edition,  Lippincott,  1917. 
Gray:  Anatomy,  Twenty-first  Edition,  Longmans  Green,  1920. 
Heisler:  Practical  Anatomy,  Second  Edition,  Lippincott,  1920. 
Howe:  The  Muscles  of  the  Eye,  Putnam,  New  York,  1907. 
Maddox:  Tests  and  Studies  of  the  Ocular  Muscles,  Second  Edition,  Philadelphia, 

1907. 


Clinical  Anatomy  of  the  Efferent  Lacrimal  Passageways       625 

Merkel:    Article  on  Makroskopische  Anatomie  des  Auges  in  Graefe-Saemisch 

Handbuch,  1901. 

Morris:  Human  Anatomy,  Sixth  Edition,  Blakiston,  1921. 
Motais:  L'appareil  moteur  de  1'oeil,  Paris,  1887. 
Piersol:  Human  Anatomy,  Seventh  Edition,  Lippincott,  1919. 
Poirier:  Charpy's  Abrege  d' Anatomie,  Masson,  Paris,  1909. 
Quain:  Elements  of  Anatomy,  Eleventh  Edition,  Longmans  Green,  1909. 
Sappey:  Traite  d' Anatomie,  Paris,  1888. 
Schaeffer:  The  Nose  and  Olfactory  Organ,  Blakiston,  1920. 
Spalteholz:  Hand  Atlas  of  Human  Anatomy,  Barker's  translation,  Third  English 

Edition,  Lippincott. 

Sobotta-McMurrich:  Atlas  and  Textbook  of  Human  Anatomy,  Saunders,  1907. 
Testut:  Traite  d' Anatomie  Humaine,  Seventh  Edition,  Doin,  Paris,  1922. 
Toldt:  Anatomischer  Atlas,  Vienna,  1914. 
Whitnall:  Anatomy  of  the  Human  Orbit,  Oxford  Medical  Publications,  Frowde, 

London,  1921. 

Young:  Handbook  of  Anatomy,  Fifth  Edition,  Davis  Co.,  1919. 
Zabel:  Anatomische  Hefte,  1900,  xv,  p.  153. 


ON  THE   CLINICAL  ANATOMY  OF  THE  EFFERENT 
LACRIMAL  PASSAGEWAYS 

J.  PARSONS  SCHAEFFER,  M.D.,  PH.D. 

Professor  of  Anatomy  and  Director  of  the  Daniel  Baugh  Institute  of  Anatomy  of  the 
Jefferson  Medical  College,  Philadelphia 

I  take  it  as  axiomatic  that  of  first  importance  is  a  knowledge  of 
the  basic  plan  of  the  anatomy  of  the  human  body  and  that,  in  the  diag- 
nosis, treatment  and  prognosis  of  diseased  states,  the  regions  and 
organs  of  the  body  must  needs  be  approached  from  the  viewpoint  of 
an  average  anatomy.  It  is  fortunate  that  there  is  such  a  constancy 
in  what  may  be  considered  basic,  and  the  wonder  is  not  that  there  are 
departures  in  anatomic  conformations  but  that  nature  so  regularly 
reproduces  that  which  is  fundamental.  Despite  the  general  truth  of 
the  foregoing  an  ideal  or  unvarying  anatomy  of  many  parts  is  uncom- 
mon. There  are  variations  in  essential  details  and  the  adherence  to 
an  arbitrary  and  so-called  fixed  normal  is  fraught  with  considerable 
danger,  since  with  variations  come  altered  size,  shape  and  topo- 
graphic relations;  moreover,  interiors  and  exteriors  of  parts  are  pro- 
foundly influenced  by  developmental  potentialities.  Anatomic  varia- 
tions of  an  organ  and  apparatus  and  of  their  relational  field  must  have 
an  important  bearing  in  diagnosis,  pathology,  clinical  medicine,  and 
40 


626  J.  PARSONS  SCHAEFFER 

surgery,  and  the  attention  given  to  this  fact  may  be  the  narrow  mar- 
gin between  success  and  failure.  It  is  this  thesis  that  I  venture  to 
support  and  develop  in  my  address  on  the  efferent  lacrimal  passage- 
ways this  evening  rather  than  enter  into  a  detailed  account  of  the 
conventional  anatomy  of  the  parts  concerned. 

GENESIS  AND  DEVELOPMENT 

It  would  be  futile  to  attempt  a  discussion  of  this  problem  without 
a  brief  presentation  of  the  embryology  of  the  efferent  lacrimal  appar- 
atus. The  genetic  and  developmental  anatomy  not  only  point  the 
way  to  a  clearer  understanding  of  the  ground  plan  of  the  anatomy, 
but  of  the  anatomic  types  and  anomalies  as  well. 

In  the  early  embryo,  extending  from  the  medial  angle  of  the  eye 
to  the  olfactory  pit,  is  the  naso-optic  (nasolacrimal)  groove  or  fissure, 
bounded  above  by  the  lateral  nasal  process  and  below  by  the  maxillary 
process.  These  embryologic,  mesenchymal  and  epithelial  covered 
processes  unite  by  coalescing  from  the  depth  toward  the  periphery, 
thus  obliterating  or  outfolding  the  intervening  groove  or  fissure.  In 
12  mm.  human  embryos,  aged  approximately  five  weeks,  a  ridge-like 
thickening  of  the  deep  layer  of  the  epithelial  lining  of  the  now  rudi- 
mentary naso-optic  groove  takes  place.  This  epithelial  ridge  grows 
and  pushes  into  the  underlying  mesenchyme  and  becomes  entirely 
separated  from  its  surface  connections  and  wholly  surrounded  by 
mesenchymal  tissue  (embryos  aged  from  thirty-six  to  forty  days). 
The  detached  solid  strand  or  cord  of  epithelial  cells  is  the  rudiment  or 
anlage  of  the  nasolacrimal  passageways,  and  while  it  corresponds  to 
the  line  of  the  previous  naso-optic  groove,  it  must  be  understood  that 
the  system  of  efferent  lacrimal  ducts  does  not  represent  a  cut-off 
portion  of  the  obliterated  groove  brought  about  by  the  coalescence  of 
the  lateral  nasal  and  maxillary  processes. 

The  rudiment  of  the  nasolacrimal  passageways  is  a  solid  cord  of 
epithelial  cells,  detached  from  its  genetic  area  and  for  a  brief  period 
entirely  surrounded  by  mesenchyme  and  without  a  lumen.  From  the 
parent  cord  of  cells  sprout  the  upper  and  lower  lacrimal  ducts,  the 
upper  part  of  the  lacrimal  sac  and  the  nasal  end  of  the  nasolacrimal 
duct,  thereby  establishing  secondary  connections  with  the  epithelium 
of  the  free  border  of  the  eyelids  and  the  nasal  fossa.  The  lumen  of 
the  several  segments  of  the  nasolacrimal  passageways  is  irregularly 
and  variously  formed.  This  is  accomplished  by  an  apparent  necro- 
biosis  and  resorption  of  some  central  cells  and  a  rearrangement  of 


Clinical  Anatomy  of  the  Efferent  Lacrimal  Passageways       627 

others.  Canalization  begins  early  at  the  ocular  end  of  the  stem  rudi- 
ment, progresses  rapidly  toward  the  nasal  end  and  is  well  advanced 
in  embryos  aged  one  hundred  days.  At  times  it  would  appear  that 
the  upper  (eye)  and  lower  (nasal)  ends  of  the  stem  rudiment  were  the 
first  and  the  mid-section  the  last  to  gain  a  lumen.  The  horizontal 


-no/ 


Fig.  1 


Fig.  2 


Fig.  3  Fig.  4 

Figs.  1,  2,  3,  4. — Photomicrographs  of  frontal  sections  of  the  heads  of  human 
embryos  showing  several  stages  in  the  development  of  the  nasolacrimal  passage- 
ways: Fig.  1,  aged  thirty-three  days;  Fig.  2,  aged  thirtv-nve  days;  Fig.  3,  aged 
thirty-six  days;  Fig.  4,  aged  forty-three  days.  X  7.  (Schaeffer:  The  Nose  and 
Olfactory  Organ.) 

nof,  Remains  of  naso-optic  furrow;  /,  nasal  fossa;  e,  eye;  d,  different  stages 
of  the  rudiment  or  anlage  of  the  nasolacrimal  passageways. 

portions  of  the  lacrimal  ducts  become  canalized  before  the  vertical 
portions.  In  embryos  aged  one  hundred  and  twenty  days  the  vertical 
segments  not  infrequently  are  solid  cords  of  epithelial  cells,  while  the 
horizontal  segments  already  possess  a  lumen.  The  canalization  of 
the  points  of  union  between  the  free  border  of  the  eyelids  and  the 


628  J.  PARSONS  SCHAEFFER 

lacrimal  ducts  is  often  deferred  for  a  later  period.  The  point  of  coal- 
escence between  the  nasal  end  of  the  sprouting  parent  cord  and  the 
inferior  nasal  meatus  is  the  last  to  become  patent — the  attenuated 
lacrimonasal  membrane  "rupturing"  approximately  at  birth  or  later. 

As  stated  elsewhere,  the  rudiment  of  the  nasolacrimal  passageways 
grows  into  the  subjacent  mesenchyme  and  becomes  encompassed  by 
it.  The  lacrimal  ducts  and  the  ocular  and  nasal  ends  of  the  nasolac- 
rimal duct  are  secondary  outgrowths  and  soon  establish  their  defini- 
tive connections.  Subsequently  (third  or  fourth  month)  a  stumpy 
cartilaginous  process  (processus  paranasalis)  arises  from  the  lateral 
wall  of  the  cartilaginous  nasal  capsule  and  surrounds  a  part  of  the 
developing  nasolacrimal  duct  segment.  The  surrounding  mesen- 
chyme ossifies  in  the  formation  of  the  maxilla,  the  lacrimal  bone  and 
the  inferior  nasal  conchal  bone;  the  related  cartilage  usually  disap- 
pears and  the  greater  portion  of  the  nasolacrimal  duct  ultimately 
becomes  encased  in  bone,  the  canalis  nasolacrimalis.  The  lacrimal 
sac  comes  to  rest  in  an  oblong,  rounded  osseous  depression,  the 
fossa  sacci  lacrimalis,  while  the  lacrimal  ducts  occupy  the  soft  tissues 
of  the  eyelids  and  a  lower  non-osseous  portion  of  the  nasolacrimal 
duct  not  infrequently  courses  in  the  mucosa  of  the  lateral  wall  of  the 
inferior  nasal  meatus.1 

ATYPICAL  DEVELOPMENT 

The  foregoing  recounts  the  origin  and  early  development  of  what 
may  be  termed  an  ideal  or  so-called  typical  efferent  lacrimal  duct 
system.  However,  there  is  early  evidence  of  variations  from  the 
ideal.  From  the  genetic  point  of  view  the  variations  in  the  anatomy 
of  the  nasolacrimal  passageways  appear  to  fall  into  three  important 
and  more  or  less  clearly  defined  groups :  First,  those  that  have  their 
basis  in  rudiment  potentials;  second,  those  due  to  early  arrests  in  the 
development  of  parts  which  should  proceed  from  the  stem  rudiment, 
and  third,  those  due  to  division  of  previously  continuous  ducts  into 
discontinuous  segments.  The  complete  dissociation  of  the  efferent 
lacrimal  ducts,  owing  to  marked  monster  formations,  might  be  con- 
sidered an  unimportant  fourth  group,  and  deserving  of  no  further 
mention  in  this  connection. 

^or  a  more  detailed  account  of  the  embryology  see  J.  Parsons  Schaeffer, 
"The  Genesis  and  Development  of  the  Nasolacrimal  Passageways  in  Man,"  Amer. 
Jour.  Anat.,  vol.  xiii,  1912. 


Clinical  Anatomy  of  the  Efferent  Lacrimal  Passageways       629 

RUDIMENT  POTENTIALS 

Rudiment  potentials  are  encountered  which  explain  such  varia- 
tions and  abnormalities  as  supernumerary  lacrimal  ducts  for  one 
or  both  eyelids;  duplication,  triplication,  et  cetera,  of  the  lacrimal 
punctum;  the  slit  and  furrow  lacrimal  punctum;  mucosal  ledges  and 
so-called  valves  within  the  nasolacrimal  passageways;  irregularities 
of  contour;  diverticula;  variations  in  the  anatomy  of  the  lacrimal 
aperture  in  the  inferior  nasal  meatus;  osseous  and  membranous  seg- 
ments of  the  nasolacrimal  duct,  etc. 

As  a  rule,  but  two  sprouts  proceed  from  the  upper  end  of  the  parent 
or  stem  rudiment,  one  becoming  the  upper  lacrimal  duct  and  the  other 
the  lower  lacrimal  duct  or  canaliculus.  However,  occasionally  one 
encounters  multiple  buds  or  sprouts,  some  of  which  develop  sufficiently 
to  establish  definitive  connections  with  the  free  border  of  the  eyelids 
and  become  supernumerary  lacrimal  ducts.  Others  fail  to  establish 
connection  with  the  eyelids  and  end  blindly.  The  majority  of  these 
additional  buds  are  resorbed  or  become  small,  blindly  ending  divertic- 
ula. Complete  supernumerary  lacrimal  ducts  also  lead  to  multiple 
lacrimal  puncta.  However,  at  times  in  the  normal  number  of  lacrimal 
ducts,  multiple  puncta  are  encountered  for  one  or  both  lids.  These 
are  readily  accounted  for  by  the  fact  that  the  lacrimal  duct  in  coalescing 
with  the  free  border  of  the  eyelid  may  do  so  over  a  relatively  extehsive 
area.  The  canalization  of  this  wide  area  of  contact- — the  lacrimo- 
conjunctival  membrane — may  be  slit-like,  oval  or  fenestrated,  the  latter 
giving  rise  to  multiple  puncta.  Indeed,  the  greater  portion  of  the 
lacrimal  duct  or  canaliculus  may  be  represented  by  a  furrow  along 
the  free  border  of  the  eyelid. 

The  canalization  of  the  solid  nasolacrimal  rudiment  occurs  very 
irregularly  and  there  is  all  evidence  at  an  early  time  of  mucosal 
ledges  and  valves  and  shallow  diverticula.  Secondary  buds  from  the 
stem  rudiment  account  for  the  larger  diverticula,  and  the  belief  that 
these  are  acquired  in  adult  life  and  the  result  of  disease  is  not  justified. 

The  variation  in  the  topography  and  type  of  the  nasolacrimal 
ostium  or  aperture  in  the  inferior  nasal  meatus  is  cleared  up  by  the 
embryology  of  the  lacrimonasal  membrane,  formed  by  the  fusion  of  the 
epithelium  of  the  nasolacrimal  duct  with  the  mucous  membrane  of 
the  nasal  fossa.  When  the  developing  nasolacrimal  duct  comes  in 
contact  with  the  nasal  mucosa  at  the  roof  and  highest  point  of  the 
inferior  nasal  meatus,  the  resulting  ostium  nasolacrimale  is  single, 


630  J.  PARSONS  SCHAEFFER 

large,  unguarded  by  a  mucosal  valve,  and,  since  it  becomes  surrounded 
by  an  osseous  ring,  stands  permanently  open.  On  the  other  hand, 
when  the  developing  nasolacrimal  duct  establishes  contact  and  fusion 
with  the  lateral  wall  of  the  inferior  nasal  meatus,  the  area  may  be  a 
considerable  one.  In  the  latter,  the  ostium  nasolacrimale  generally 
is  slit-like  and  has  a  mucosal  flap  or  valve.  This  valve  may  or  may 
not  be  efficient  physiologically  in  preventing  regurgitation.  The 
aperture  may  be  single  or  multiple  and  located  variously  on  the  lateral 
wall  of  the  inferior  nasal  meatus,  from  the  attached  border  of  the 
inferior  nasal  concha  to  the  floor  of  the  nose.  Varieties  of  these  two 
basic  types  of  nasolacrimal  ostia  or  apertures  are  very  frequently 
encountered,  but  a  discussion  of  them  is  not  vital  in  this  connection. 

The  posterior  lacrimal  crista  is  very  prominent  in  the  newborn, 
rendering  the  lacrimal  fossa  relatively  deep.  The  hamular  process 
of  the  lacrimal  bone  at  times  undergoes  conspicuous  development, 
resulting  in  division  of  the  lacrimal  sac. 

DEVELOPMENTAL  ARRESTS 

Patients  are  encountered  with  one  or  both  lacrimal  ducts  wanting 
in  whole  or  in  part;  or  if  complete,  the  point  of  coalescence  with  the 
eyelids  may  be  imperforate,  or  atresias  over  greater  segments  may  be 
encountered.  The  connection  with  the  inferior  nasal  meatus  may  be 
defective  or  absolutely  imperforate.  Atresias  of  portions  of  the  naso- 
lacrimal passageways  are  not  uncommon  in  the  newborn. 

The  stem  rudiment  may  not  become  detached  wholly  from  its 
original  surface  connections,  thereby  leading  to  lacrimal  fistulse  or 
false  adult  connections.  This  is  especially  prone  to  occur  in  the 
region  of  the  lacrimal  sac.  The  nasal  end  of  the  stem  rudiment  may 
fail  to  sprout  or  may  establish  connections  with  the  middle  nasal 
meatus  by  means  of  a  side  bud.  Connections  may  be  made  with  the 
lip,  and  the  lower  orifice  of  the  nasolacrimal  duct  established  there. 

The  cause  for  the  failure  of  normal  development  is  not  clear.  So 
far  as  the  lacrimal  ducts  are  concerned,  there  appears  to  be  a  critical 
period  for  them  shortly  after  the  detachment  of  the  solid  epithelial 
rudiment  of  the  nasolacrimal  passageways  from  its  surface  connection. 
If  the  lacrimal  ducts  which  normally  grow  as  secondary  sprouts  from 
the  stem  rudiment  fail  to  show  beginning  growth  shortly  after  this 
stage,  there  appears  to  be  a  great  likelihood  that  they  will  not  develop 
subsequently.  Since  the  rudiments  are  solid  epithelial  cords,  want 
of  canalization  will  lead  to  atresias  of  various  degrees  and  levels  later. 


Clinical  Anatomy  of  the  Efferent  Lacrimal  Passageways       631 

These  are  most  common  at  the  distal  or  nasal  end  of  the  nasolacrimal 
duct  in  the  newborn  and  child.  It  would  appear  that  many  of  the 
latter  atresias  become  perforate  during  the  first  weeks  or  months  of 
extrauterine  life.  Atresias  of  the  lacrimal  ducts  or  canaliculi  also 
are  encountered.  There  also  is  some  evidence  of  obliteration  of  a 
previously  established  lumen  by  a  secondary  proliferation  of  the 
epithelial  lining  of  the  ducts,  especially  the  nasolacrimal  duct. 

OTHER  ANOMALOUS  CONDITIONS 

There  are  a  few  anomalous  conditions  in  the  anatomy  of  the 
nasolacrimal  passageways  that  appear  to  have  no  basis  in  the  rudi- 
ment potentials  nor  in  arrested  development.  For  example,  divided 
lacrimal  ducts  are  encountered,  the  lacrimal  sac  may  be  detached  from 
the  main  nasolacrimal  duct,  the  nasolacrimal  duct  proper  may  be 
found  as  two  discontinuous  segments,  etc.  It  appears  certain  that 
the  division  of  a  lacrimal  duct  or  of  the  nasolacrimal  duct  proper 
occurs  secondarily;  that  is,  after  the  definitive  connections  are  fully 
formed.  These  conditions  often  occur  in  monsters  or  in  children  with 
secondary  facial  fissures.  Ask  and  van  der  Hoeve1  suggest  amniotic 
bands  and  ingeniously  use  secondary  facial  furrows  and  the  develop- 
ment of  the  lacrimal  caruncle  in  attempting  to  establish  their  thesis. 
Ask's  previous  conclusions  on  the  development  of  the  lacrimal  caruncle 
are  generally  accepted  as  correct.2  It  is  my  belief,  for  example,  that 
the  lacrimal  ducts  wholly  grow  from  the  ocular  end  of  the  stem  rudi- 
ment of  the  nasolacrimal  passageways  and  not,  as  some  argue,  one 
part  from  the  free  border  of  the  eyelid  and  the  other  from  the  stem 
rudiment.  Therefore,  when  one  encounters  a  lacrimal  duct  with 
normal  definitive  connections,  divided  into  two  discontinuous  seg- 
ments, there  is  no  other  explanation  but  that  the  duct  suffered  divi- 
sion secondarily.  The  same  applies  elsewhere.  Amniotic  bands  are 
suggestive  in  this  connection  and  are  deserving  of  further  study. 
The  discussion,  however,  cannot  be  extended  here. 

1  Fritz  Ask  und  J.  van  der  Hoeve:  Beitrage  zur  Kenntnis  der  Entwicklung  der 
Tranenrohrchen  unter  normalen  und  abnormen  Verbal tnissen,  letzteres  an  Fallen 
von  offener  schrager  Gesichtsspalte,  von  Graefe's  Archiv  fur  Ophthalmologie,  cv, 
1921. 

2  Ask,  Fritz :  Uber  die  Entwicklung  der  Caruncula  lacrimalis  beim  Menschen, 
nebst  Bemerkungen  iiber  die  Entwicklung  der  Tranenrorchen  und  der  Meibom- 
schen  Driisen,  Anatom.  Anz.,  xxx,  1907. 


632T 


J.  PARSONS  SCHAEFFER 


EARLY  POSTUTERINE  DEVELOPMENT 

The  nasolacrimal  duct  at  birth  has  very  irregular  walls.  The 
ragged  mucosal  surface  gradually  changes  to  a  more  even  contour. 
However,  some  of  the  recesses  remain  and  others  become  extended 
into  goodly  sized  diverticula.  Some  of  the  mucosal  fringes  undergo 
definite  organization  and  form  permanent  mucosal  ledges  and  valves 
within  the  ducts.  Not  infrequently  the  nasal  end  of  the  nasolacri- 
mal duct  is  imperf orate  at  birth.  Many  of  these  go  unrecognized, 
becoming  perforate  in  the  early  weeks  of  extrauterine  life  and  showing 


Fig.  5. — a,  Photograph  of  a  section  through  the  nasal  end  of  the  nasolacrimal 
duct,  showing  a  lacrimonasal  membrane  of  considerable  thickness  and  imper- 
forate. Fetus  aged  seven  months,  b,  Note  lacrimonasal  membrane  thinned  out 
but  imperforate.  Newborn  child,  c,  Section  of  the  entire  nasolacrimal  duct, 
showing  great  irregularity  of  lumen.  The  communication  with  the  inferior  nasal 
meatus  is  established.  Child  aged  one  month. 

that  developmental  processes  are  carried  on  after  birth.  However, 
some  remain  imperforate  for  a  longer  period  and  give  definite  symp- 
toms. They  may  become  perforate  spontaneously,  even  after  the 
first  year.  While  an  expectant  treatment  should  be  adopted,  opera- 
tive procedures  may  be  required. 

The  nasolacrimal  duct  at  birth  averages  less  than  2  mm.  .in  diame- 
ter, at  the  third  year  3  mm.,  with  extremes  of  1.5  mm.  to  6  mm., 
the  latter  being  rare.  The  osseous  nasolacrimal  canal  is  somewhat 
larger.  The  subepithelial  tissue  stratum  harbors  a  plexus  of  veins 
and  lymphoid  tissue. 


Clinical  Anatomy  of  the  Efferent  Lacrimal  Passageways       633 

The  outlet  into  the  inferior  nasal  meatus  is  extremely  variable  at 
an  early  time  and  is  subject  to  the  same  influences  that  obtain  in  the 
adult.  Since  these  will  be  discussed  at  length  subsequently,  they 
need  not  detain  us  here. 

The  plane  of  direction,  in  the  infant,  of  the  lacrimal  fossa  and  the 
nasolacrimal  canal,  with  the  contained  lacrimal  sac  and  the  naso- 
lacrimal  duct,  is  more  direct  and  more  nearly  vertical.  As  age  ad- 
vances the  plane  of  projection  of  the  canal  and  duct  must  conform 
to  the  type  of  face,  size  of  the  inferior  meatus,  width  of  the  pyriform 
aperture  and  the  width  of  the  bridge  of  the  nose,  which  take  definition 
and  become  more  and  more  positive  as  puberty  is  neared. 

MACROSCOPIC  ANATOMY 

The  Lacrimal  Fossa  and  the  Nasolacrimal  Canal. — The  osseous 
fossa  which  lodges  the  membranous  lacrimal  sac  (fossa  sacci  lacri- 
malis)  is  an  oblong,  rounded  depression  located  on  the  ventro-medial 
aspect  of  the  orbit, — the  frontal  process  of  the  maxilla  and  the  lacri- 
mal bone  participating  more  or  less  equally  in  its  formation.  The 
fossa  is  limited  dorsally  by  the  posterior  lacrimal  crista  and  ventrally 
by  the  anterior  lacrimal  crista,  the  former  a  prominent  crest  on  the 
lacrimal  bone  (especially  conspicuous  in  the  newborn)  and  the  latter 
a  crest  on  the  frontal  process  of  the  maxilla.  Above,  the  lacrimal 
fossa  becomes  shallower  and  shallower,  ultimately  losing  its  identity 
at  the  fronto-lacrimo-maxillary  suture  line,  while  below  it  is  directly 
confluent  with  the  osseous  nasolacrimal  canal.  The  latter  terminates 
immediately  below  the  attached  border  of  the  inferior  nasal  concha 
at  the  cupola  of  the  inferior  nasal  meatus.  The  osseous  canal  is 
formed  by  the  maxilla,  the  lacrimal  bone  and  the  inferior  nasal 
concha,  the  maxilla  by  its  frontal  process  and  body  contributing  the 
greater  portion.  Variations  occur. 

The  length  of  the  osseous  nasolacrimal  canal  does  not  necessarily 
conform  to  the  enclosed  membranous  nasolacrimal  duct,  which  is 
frequently  longer  (see  elsewhere).  The  osseous  canal  proper  varies 
in  length  from  10  to  20  mm.,  and  the  lacrimal  fossa  from  10  to  14  mm., 
making  the  total  length  of  the  osseous  channels  from  20  to  34  mm. 
The  diameter  of  the  osseous  canal  is  seldom  uniform  throughout, 
measuring  on  an  average  5  mm.  at  its  narrowest  part  and  8  mm.  at 
its  widest.  Extremely  narrow  (2  mm.)  segments  are  occasionally 
encountered.  At  times  the  widest  point  is  apove  and  the  narrow 
point  at  its  inferior  outlet.  Again,  the  reverse  may  be  true,  or  the  nar- 


634  J.  PARSONS  SCHAEFFER 

row  part  be  in  the  mid-section.  These  congenitally  constricted  seg- 
ments simulate  a  stricture  in  passing  the  lacrimal  probe. 

The  plane  of  direction  of  the  osseous  nasolacrimal  canal  obviously 
conforms  to  the  type  of  the  facial  skeleton.  The  breadth  of  the 
bridge  of  the  nose,  the  width  of  the  inferior  nasal  meatus,  and  the 
degree  of  expansion  of  the  pyriform  aperture  also  influence  the  course 
or  direction  of  the  nasolacrimal  canal.  Generally  speaking,  one  may 
say  that  the  osseous  nasolacrimal  canal  is  projected  caudal  ward, 
lateral  ward  and  dorsalward .  Its  surface  mark  is  an  oblique  line  erected 
from  the  lacrimal  fossa  to  a  variable  point  on  the  medial  aspect  of  the 
alveolar  process  of  the  maxilla,  corresponding  to  the  interval  between 
the  second  premolar  and  the  first  molar,  the  first  and  second  molars 
or  even  as  far  dorsal  as  the  second  and  third  molar  teeth.  The 
almost  vertical  plane  frequently  shown  in  text-books  is  erroneous. 

The  Lacrimal  Ducts. — The  lacrimal  ducts  or  canaliculi  begin  nor- 
mally by  minute  openings,  the  lacrimal  puncta,  which  either  surmount 
or  are  placed  on  the  sides  of  the  conical  lacrimal  papillae,  located  on  the 
free  border  of  the  eyelids,  the  upper  about  6  mm.  and  the  lower  about 
8  mm.  from  the  medial  palpebral  commissure  (internal  can  thus). 
The  puncta  normally  are  directed  against  the  eyeball,  and  should 
there  be  a  malposition  (congenital  or  acquired)  of  the  puncta 
there  is  usually  an  overflow  of  tears.  The  same  results  if  the  lumen 
is  obstructed.  The  lacrimal  ducts  consist  of  vertical  and  horizontal 
portions,  with  dilatations  or  ampullae  at  the  knees.  They  average 
from  8  to  10  mm.  in  their  total  length;  0.1  to  0.2  mm.  in  diameter  at 
the  puncta,  1  mm.  at  the  knees  and  0.5  to  0.8  mm.  in  the  horizontal 
portion.  The  inferior  lacrimal  duct  almost  invariably  is  longer  than 
the  superior  duct.  Irregularities  and  sacculations  of  the  lumen  are 
not  infrequent. 

The  horizontal  portions  of  the  lacrimal  ducts  communicate  with  the 
lacrimal  sac  (a)  by  the  ducts  uniting  into  a  short,  narrow  common 
duct,  (b)  by  each  duct  emptying  separately  into  a  diverticulum  of  the 
lacrimal  sac  and  (c)  by  the  ducts  emptying  separately  directly  into 
the  lacrimal  sac.  The  first/  is  the  most  frequent. 

The  Lacrimal  Sac  and  the  Nasolacrimal  Duct. — The  membranous 
lacrimal  sac  occupies  the  lacrimal  fossa  and  extends  for  some  dis- 
tance into  the  upper  end  of  the  nasolacrimal  canal.  It  is  bridged  over 
by  the  palpebral  fascia,  which  extends  from  the  anterior  to  the  pos- 
terior lacrimal  crests;  the  medial  palpebral  ligament;  fibers  of  the 
orbicularis  palpebrarum  and  skin  and  subcutaneous  tela.  The 


Clinical  Anatomy  of  the  Efferent  Lacrimal  Passageways       635 

orifice  (or  orifices)  of  the  lacrimal  ducts  usually  is  located  from  2  to 
5  mm.  from  the  extreme  top  or  fornix  of  the  lacrimal  sac. 

The  lacrimal  sac  at  times  merges  imperceptibly  with  the  naso- 
lacrimal  duct.  Again,  there  may  be  a  slight  or  marked  constriction 
or  isthmus,  or  the  lacrimal  sac  and  the  nasolacrimal  duct  may  not  be 
in  alignment,  but  joined  side  by  side.  It  will  be  recalled  that  the 
osseous  nasolacrimal  canal  terminates  at  the  highest  point  of  the  in- 
ferior nasal  meatus.  The  contained  membranous  nasolacrimal 
duct  may  or  may  not  conform  to  this  termination.  At  times  the 
nasolacrimal  duct  is  continued  for  a  considerable  distance  within  the 
mucous  membrane  of  the  lateral  wall  of  the  inferior  nasal  meatus, 
beyond  the  nasal  end  of  the  osseous  nasolacrimal  canal.  This 
accounts  for  the  discrepancy  in  length  between  the  membranous 
nasolacrimal  duct  and  the  osseous  nasolacrimal  canal;  moreover, 
leading  to  an  osseous-supported  segment  of  the  duct  and  a  purely 
membranous  segment.  The  latter  has  an  important  clinical  sig- 
nificance (see  elsewhere). 

Since  the  ostium  of  the  nasolacrimal  duct  varies  in  its  location,  the 
nasolacrimal  duct  has  a  range  in  length  from  10  to  28  mm.  The 
diameter  of  the  nasolacrimal  duct  is  not  uniform.  At  times  the 
isthmus  is  much  constricted,  3  mm.,  the  remaining  portion  of  the 
duct  averaging  approximately  5  mm.  However,  this  is  much  re- 
duced at  times  by  encroachment  of  the  osseous  canal  or  by  an  unusual 
development  of  the  subepithelial  strata.  The  nasolacrimal  duct  may 
be  wide  above  and  narrow  below,  narrow  above  and  wide  below,  or 
hour-glass  in  character,  i.  e.,  constricted  midway. 

Diverticula  and  Valves. — A  large  number  of  nasolacrimal  ducts  have 
fairly  regular  and  uniform  walls.  However,  not  infrequently  there 
is  a  retention  of  developmental  structures  leading  to  the  formation 
of  valve-like  folds  and  diverticula,  with  great  irregularity  of  the  lumen 
of  the  duct.  Krause  and  Beraud  long  ago  described  a  valve  at  the 
junction  of  the  lacrimal  sac  and  the  lacrimal  duct.  Frequently  this 
is  merely  an  elevation  of  mucosa.  Again,  it  may  be  sufficiently 
reduplicated  to  form  a  true  valve.  Bochdalek  and  the  writer  have 
found  that  the  opening  of  the  lacrimal  ducts  may  be  placed  in  the 
center  of  a  mucous  membrane  diaphragm.  Additional  valves  and 
mucosal  ledges  are  not  infrequently  encountered  in  the  mid-portion 
of  the  nasolacrimal  duct. 

Lateral  evaginations  of  the  mucosa  result  in  minor  depression  and 
fossae.  However,  at  times  these  extensions  are  of  considerable  pro- 


636  J.  PARSONS  SCHAEFFER 

.  portions,  leading  to  the  formation  of  variously  sized,  blindly  ending 
diverticula.  These  diverticula  have  a  lining  not  unlike  that  of  the 
nasolacrimal  duct  proper,  with  which  they  always  communicate. 
The  genesis  of  these  diverticula  seems  established,  and  from  the 
evidence  at  hand  one  must  conclude  that  they  are  congenital  rather 
than  acquired. 

The  anomalies  of  the  efferent  passageways  were  briefly  discussed  in 
connection  with  the  development,  therefore,  no  further  mention  of 
them  need  be  made  here. 

MICROSCOPIC  ANATOMY 

The  lacrimal  ducts  have  a  lining  of  stratified  squamous  epithelium 
superimposed  upon  a  sparse  tunica  propria  rich  in  elastica.  Fibers 
of  the  orbicularis  oculi  muscle  lend  strength  and  support,  paralleling 
the  horizontal  segment  of  the  ducts  and  encircling  the  vertical  seg- 
ment. The  circular  fibers  are  in  essence  a  true  sphincter  and  are  so 
arranged  that  from  the  physiological  point  of  view  the  lumen  of  the 
ducts  is  readily  occluded.  This  may  be  brought  about  reflexly  follow- 
ing excitation  in  the  immediate  neighborhood  or  at  a  remote  and  unsus- 
pected point.  There  may,  therefore,  be  an  overflowing  of  tears  from 
a  physiologic  obstruction  of  the  very  beginning  of  the  efferent 
lacrimal  passageways. 

The  lacrimal  sac  has  a  lining  of  columnar  epithelial  cells,  usually 
arranged  in  a  double  layer.  Here  and  there  the  surface  cells  are 
provided  with  cilia.  Beneath  the  epithelium  is  a  relatively  thick 
fibro-elastic  tunica  propria  with  an  abundance  of  lymphoid  tissue, 
some  of  which  is  arranged  in  definite  masses  not  unlike  the  aggregated 
nodules  of  the  small  intestine.  Small  tubular  glands  are  always 
present;  in  some  specimens  in  great  abundance,  in  others  but  few  are 
found.  Not  infrequently  numerous  elements  of  epithelium  exhibit 
stages  of  conversion  into  mucus-containing  goblet  cells.  These  may 
be  found  over  considerable  stretches  of  epithelium.  Here  and  there 
the  epithelium  becomes  depressed  and  gland-like,  goblet-cells  lining 
the  depressions.  The  tubular  glands  not  infrequently  contain  goblet- 
cells. 

Another  important  anatomic  feature  is  the  loose  tissue  which 
connects  the  tunica  propria  with  the  periosteum.  This  tissue  every- 
where is  occupied  by  a  rich  plexus  of  veins  which  partakes  of  the  nature 
of  a  modified  erectile  tissue.  The  tissue  spaces  are  large.  This 
stratum  is  subject  to  very  rapid  engorgement  and  depletion,  and 


Clinical  A  natomy  of  the  Efferent  Lacrimal  Passageways       637 

under  reflex  and  pathologic  conditions  may  increase  in  thickness 
many  fold.  There  is  every  reason  that  this  stratum  can  be  influenced 
reflexly  owing  to  the  excessive  venous  plexus.  Complete  physio- 
logic obstruction  of  the  lumen  of  the  lacrimal  sac  may  ensue  from  its 
engorgement. 

The  nasolacrimal  duct  also  is  lined  with  a  columnar  epithelium. 
Small  tubular  glands  are  encountered — most  of  the  mucous  type,  others 
appear  mucoserous  in  character.  Between  the  epithelium  and  the 


a  b 

Fig.  6. — a,  A  section  of  the  mucous  membrane  of  the  lacrimal  sac,  considerably 
magnified.  Note,  e,  the  epithelium  with  glands  and  goblet  cells;  /,  lymphoid 
tissue,  nodular-like  in  character;  and,  v,  the  large  venous  spaces,  b,  Same  as  a, 
at  a  lower  magnification;  showing  a  larger  field  and  the  great  venous  plexus  in 
the  tunica  propria.  The  blood-spaces  are  all  engorged. 

periosteum  is  a  stratum  of  very  loose  areolar  tissue  with  an  abundant 
venous  plexus.  The  lower  part  of  the  duct  is  not  unlike  the  erectile 
mucosa  of  the  inferior  nasal  concha  and  the  related  meatus. 

One  cannot  but  be  impressed  with  the  abundant  venous  plexus  of 
the  lacrimal  sac  and  the  nasolacrimal  duct.  Its  real  significance  has 
not  been  determined.  At  times  and  in  places  it  is  suggestive  of  an 
erectile  tissue.  One  wonders  whether  this  stratum  of  the  lacrimal  sac 
and  the  nasolacrimal  duct  is  subject  to  the  same  influences  as  are  the 
erectile  tissues  of  the  nose.  The  clinical  potentialities  here  appear 


638  J.  PARSONS  SCHAEFFER 

great.  Reflex  neuroses  may  be  a  factor.  However,  in  obscure  cases 
careful  search  should  be  made  for  a  disease  focus  which  invokes  a 
reflex  turgescence  and  a  possible  physiologic  occlusion  of  the  naso- 
lacrimal  duct.  It  also  is  remotely  possible  that  over-sexual  activity 
may  have  a  bearing  as  it  does  in  nasal  conditions.  Of  course,  primary 
and  secondary  infection  also  markedly  thickens  the  mucosa;  especially 
is  the  venous  plexus  engorged  and  the  lymph oid  tissue  multiplied. 
Another  striking  anatomic  feature  is  the  glands  and  the  many 
mucus-containing  goblet-cells.  The  anatomy  is  such  that  should 
the  nasal  outlet  be  interfered  with  a  mucocele  of  the  nasolacrimal  duct 
and  the  lacrimal  sac  could  readily  follow.  In  view  of  the  foregoing 
one  wonders  whether  the  lacrimal  sac  and  the  nasolacrimal  duct  are 
merely  conveyors  of  fluid  (tears)  or  whether  an  additional  function 
should  be  ascribed. 

THE  EXTRAMURAL  RELATIONS 

The  etiological  connection  between  affections  of  the  nasolacrimal 
passageways,  the  nasal  fossae  and  the  paranasal  sinuses  is  established 
beyond  perad venture.  This  does  not  minimize  the  important  ana- 
tomic and  clinical  connections  between  the  efferent  lacrimal  passage- 
way sand  the  conjunctival  culdesac.  de  Schweinitz  says:  "Although 
it  might  seem  natural  that  conjunctivitis,  and  especially  purulent 
conjunctivitis,  should  cause  lacrimal  disease,  this  is  by  no  means 
frequently  the  case."1  Kuhnt  placed  the  nasal  and  paranasal  origin 
of  disease  of  the  nasolacrimal  passageways  as  high  as  93.7  per  cent. 
Others  consider  this  too  high.  All,  however,  agree  that  the  nasal 
cavity  and  its  ancillary  structures  are  fruitful  fields  from  which 
disease  spreads  to  the  nasolacrimal  passageways.  Therefore,  a  brief 
consideration  of  the  underlying  anatomy  is  in  order. 

A.     THE  PARANASAL  SINUSES 

The  Newborn  and  Child. — At  birth  the  nasolacrimal  duct  lies  approx- 
imately 2  mm.  directly  in  front  of  and  from  1}^  to  2  mm.  medial  to 
the  ventral  end  of  the  maxillary  sinus.  By  the  eighteenth  month  the 
distance  intervening  between  the  maxillary  sinus  and  the  nasolac- 
rimal duct  is  reduced  for  a  limited  segment  of  the  duct  to  an  intimacy 
not  unlike  that  in  the  adult.  Later,  when  the  infraorbital  recess  as- 
sumes larger  proportions,  the  nasolacrimal  duct  and  the  maxillary 
sinus  come  into  intimate  relationship  for  a  considerable  distance.  Of 

1  George  E.  de  Schweinitz,  Diseases  of  the  Eye,  8th  edition,  page  569,  1916. 


Clinical  Anatomy  of  the  Efferent  Lacrimal  Passageways       639 

the  ethmoidal  cells,  those  developing  from  the  frontal  recess  are 
nearest  the  lacrimal  sac  at  birth.  Topographic  relationship  is,  how- 
ever, not  intimate  at  this  time.  Even  at  two  years  as  much  as  5  mm. 
intervenes  between  the  lacrimal  sac  and  the  nearest  ethmoidal  cell, 
save  in  precocious  development,  when  intimate  relationships  are 
established  very  early.  In  the  sixth  year  the  upper  segment  of  the 
nasolacrimal  duct  and  the  maxillary  sinus  are  intimately  related,  and 
the  anterior  ethmoidal  cells  (frontal  and  infundibular)  have  pneu- 
matized  the  region  formerly  existing  between  the  lacrimal  sac  and  the 
frontal  recess.  Even  the  rudimentary  frontal  sinus  may  have  close 
relationships  at  an  early  time.  After  the  eighth  year  the  anatomic 
relationships  between  the  paranasal  sinuses  and  the  nasolacrimal 
passageways  are  in  essence  those  of  the  adult. 

The  Adult. — The  frontal  and  maxillary  sinuses  and  the  anterior 
group  of  ethmoidal  cells  need  to  be  mentioned  in  this  connection,  and 
of  these  the  latter  are  of  special  importance.  Even  the  posterior 
ethmoidal  cells  when  they  pneumatize  extensively  forward  into  the 
middle  nasal  concha  (conchal  cells)  may  have  a  bearing  in  this  con- 
nection. 

Very  commonly  two  or  more  ethmoidal  cells  which  develop  from 
the  frontal  recess  and  the  ethmoidal  infundibulum  come  into  very 
intimate  relationship  with  the  dorsal  and  medial  aspects  of  the  lacri- 
mal sac.  Indeed,  at  times  the  entire  lacrimal  fossa  and  the  upper  part 
of  the  nasolacrimal  canal  are  pneumatized  by  ethmoidal  cells,  variously 
related  to  the  lacrimal  sac  and  the  upper  part  of  the  nasolacrimal  duct. 
These  ethmoidal  cells  for  the  most  part  arise  from  the  ethmoidal 
infundibulum  and  the  frontal  recess  and  extend  into  the  agger  nasi, 
the  uncinate  process,  the  frontal  process  of  the  maxilla,  and  the 
lacrimal  bone.  While  ethmoidal  cells  most  frequently  are  located 
medial  and  dorsal  to  the  lacrimal  sac  and  the  upper  part  of  the  naso- 
lacrimal duct,  they  also  are  found  cap-like  over  the  cupola  of  the 
lacrimal  sac  and  occasionally  develop  lateroventrally  covering  the 
lacrimal  sac  at  the  medial  palpebral  commissure.  The  expansion  of 
the  ethmoidal  cells  (anterior  or  posterior)  into  the  middle  nasal 
concha  also  is  a  factor.  These  readily  become  the  seat  of  a  mucocele, 
pyocele,  etc. 

The  almost  constant  extension  of  ethmoidal  cells  from  the  frontal 
recess  and  the  ethmoidal  infundibulum  on  the  nasal  side  of  the  lacrimal 
sac  are  of  practical  importance  since  dacryocystorhinostomy  is  prac- 
tised in  this  location.  Of  course,  when  the  nasolacrimal  duct  is 


640 


J.  PARSONS  SCHAEFFER 


operated  on  in  its  lower  third,  the  ethmoidal  cells  in  question  are 
avoided. 

The  osseous  party  walls  between  the  lacrimal  sac  and  the  upper 
segment  of  the  nasolacrimal  duct  and  the  ethmoidal  cells  are  at  best 
reduced  to  extremely  thin  and  delicate  lamellae.  Not  infrequently 
the  osseous  partitions  are  partly  or  wholly  defective  whereby  the 
mucoperiosteal  layers  of  the  related  parts  become  contiguous. 

The  nasolacrimal  duct  courses  in  the  osseous  nasolacrimal  canal, 


Dvctas  nasofrontalis 

I  ltifiLti4tib.af  frontal  sums/ 

lnfuidAulu.il  gtfiHteielalt 
Aaoer  nasi  cell....  ...\ 

ff  *Hr*»Mi^,.l.--     ~-.*r»\ 


(Sinua 


prcla£ri»ialis,     '1 


(ktuan  dacha  n 


Jtfcesses .-'' 


Fig.  7. — A  dissection  of  the  lateral  nasal  wall  with  especial  reference  to  the 
nasolacrimal  duct,  the  lacrimal  sac  (indicated  by  dotted  outline,  in  white),  the 
agger  nasi  cell,  and  the  prelacrimal  recess  of  the  sinus  maxillaris.  (Schaeffer:  The 
Nose  and  Olfactory  Organ.) 

located  in  the  nasal  wall  of  the  maxillary  sinus.  Almost  constantly 
this  wall  of  the  maxillary  sinus  is  pushed  into  a  bold,  mound-like 
relief  by  the  nasolacrimal  canal  and  its  contained  duct.  Another 
very  important  relationship  of  the  maxillary  sinus  is  the  forward  and 
cephalic  expansion  of  the  sinus  in  the  formation  of  the  prelacrimal  or 
infraorbital  recess.  This  recess  is  often  of  conspicuous  size  and  hol- 
lows out  the  osseous  boundary  on  the  dorsal  and  nasal  side  of  the 
lacrimal  sac  and  more  frequently  of  the  nasolacrimal  duct.  Unless 


Clinical  Anatomy  of  the  Efferent  Lacrimal  Passageways       641 

one  bears  this  expansion  of  the  maxillary  sinus  in  mind  in  surgical 
endonasal  procedures,  the  sinus  is  readily  opened  into  instead  of  the 
osseous  nasolacrimal  canal  and  the  membranous  duct.  Where  the 
recess  is  very  extensive,  opening  into  it  may  be  unavoidable.  As 
elsewhere,  the  osseous  party  walls,  not  infrequently,  are  extremely 
thin,  even  to  the  point  of  dehiscences. 

The  frontal  sinus  usually  does  not  bear  an  intimate  relationship  to 
the  lacrimal  sac  and  the  nasolacrimal  duct.  However,  when  the 
pneumatization  extends  into  the  nasal  bone,  the  frontal  process  of  the 
maxilla  and  the  lacrimal  bone,  beyond  the  confines  of  the  suture  line 
separating  these  bones  from  the  frontal,  the  frontal  sinus  bears  a 
direct  and  at  times  a  very  intimate  relationship  to  the  lacrimal  sac 
and  the  fossa  which  lodges  it.  That  is,  the  frontal  sinus  extends  into 
the  walls  of  the  lacrimal  fossa.  The  osseous  partition  between  the 
frontal  sinus  and  the  lacrimal  sac  is,  as  a  rule,  of  considerable  thickness. 
However,  it  may  be  reduced  to  a  papery  delicacy  or  be  defective. 

The  paranasal  sinuses,  especially  the  anterior  ethmoidal  (frontal 
and  infundibular),  may  develop  to  such  an  extent  and  in  such  direc- 
tion as  to  encroach  upon  the  lacrimal  sac  and  the  upper  segment  of 
the  nasolacrimal  duct  and  mechanically  affect  their  lumen.  If,  how- 
ever, the  enlargement  of  the  ethmoidal  cells  is  wholly  on  the  dorsal 
and  medial  aspects  of  the  lacrimal  sac  the  latter  is  crowded  merely 
ventrally  and  laterally,  since  there  is  no  bone  to  prevent  bulging  in  this 
direction.  The  nasolacrimal  duct  may  be  profoundly  influenced  by 
the  ethmoidal  cells,  the  maxillary  sinus  and  the  conchal  cells,  since  it 
is  imprisoned  in  an  osseous  canal  and  is  readily  pinched  by  pressure 
or  by  cells  pneumatizing  its  walls.  Again,  the  lacrimal  sac  and  the 
nasolacrimal  duct  may  be  encroached  upon  by  the  paranasal  sinuses 
actually  invading  the  walls  of  the  lacrimal  fossa  and  the  nasolacrimal 
canal.  The  degree  of  this  encroachment  is  variable  and  depends 
upon  the  number  of  cells  differentiated,  the  direction  of  growth  and 
the  size  attained.  While  the  intimate  topographic  relations  of  the 
paranasal  sinuses  and  the  nasolacrimal  passageways  usually  are  of 
importance  only  in  diseased  states,  the  fact  remains  that  occasionally 
in  healthy  cells  and  sinuses  the  encroachment  on  the  lacrimal  sac  and 
the  ocular  end  of  the  nasolacrimal  duct  is  such  as  to  mechanically 
obstruct  to  a  greater  or  less  degree  the  lumen  of  the  passageways. 

The  incidence  of  nasal  and  paranasal  disease  is  greater  than  that  of 
the  efferent  lacrimal  passageways.  However,  the  direct  or  indirect 
transference  of  chronic  disease  from  the  paranasal  sinuses  to  the  tear 
41 


642  J.  PARSONS  SCHAEFFER 

passageways  is  well  established  clinically.  Apart  from  the  intimate 
topographic  relationships  already  referred  to  there  are  other  contrib- 
uting factors.  The  bony  party  walls  frequently  are  extremely  thin 
or  web-like.  Again,  they  may  be  fenestrated,  or  single,  large  con- 
genital dehiscences  may  be  encountered.  The  venous  plexuses  of  the 
mucosa  of  the  nasal  fossa,  the  paranasal  sinuses  and  the  lacrimal  sac 
and  the  nasolacrimal  duct  freely  communicate.  The  lymphatic  net- 
works of  the  parts  also  connect  up,  and  where  the  osseous  party  wall 
is  fenestrated  or  defective,  the  abundant  tissue  spaces  are  in  direct 
relation.  The  venous  plexuses  of  the  nasolacrimal  passageways  con- 
nect with  the  facial,  infraorbital  and  ophthalmic  veins  and  Zucker- 
kandl  has  described  a  lacrimonasal  vein  which  perforates  the  lacrimal 
bone  and  connects  with  a  goodly  sized  vessel  emerging  from  the  sub- 
mucosal  venous  plexus  of  the  anterior  ethmoidal  cells.  These  ana- 
tomic features  explain  the  spread  of  infection  from  the  nasal  fossa  and 
the  paranasal  sinuses  to  the  nasolacrimal  passageways  and  vice  versa. 
Contiguous  tissue  spaces  and  planes  of  tissue  may  be  involved  in 
diseased  states.  The  blood  and  lymph  vascular  systems  also  are 
factors.  Thin,  bony  party  walls  may  be  perforated  and  pus  foci 
established  between  the  ethmoidal  cells  and  the  lacrimal  sac,  between 
the  lacrimal  sac  and  the  lacrimal  fossa,  and  between  the  lacrimal  sac 
and  the  skin,  the  latter  frequently  resulting  in  the  formation  of 
fistulas.  Again,  the  party  walls  may  break  down  entirely  and  an 
empyema  of  ethmoidal  cells  directly  transferred  to  the  lacrimal  sac 
and  duct.  The  opposite  also  occurs,  whereby  ethmoidal  cell  and 
maxillary  sinus  suppuration  is  secondary  to  diseased  states  of  the 
efferent  lacrimal  passageways. 

B.  THE  NASOLACRIMAL  OSTIUM  AND  THE  INFERIOR  NASAL  MEATUS 
The  nasolacrimal  ostium  or  aperture  in  the  inferior  nasal  meatus 
may,  from  the  clinical  viewpoint,  be  divided  into  five  types:  (1)  those 
that  fail  of  canalization,  that  is,  the  lacrimonasal  membrane  remains 
intact;  (2)  those  of  microscopic  size,  therefore  wholly  inadequate  for 
the  function  intended;  (3)  those  located  at  the  highest  point  of  the 
inferior  nasal  meatus  and  unguarded  by  a  valve-like  fold  of  mucous 
membrane  and  because  of  complete  osseous  walls  are  wide-mouthed 
and  stand  permanently  open;  (4)  those  located  in  the  mucous  mem- 
brane of  the  lateral  wall  of  the  inferior  nasal  meatus  some  distance 
below  the  attached  border  of  the  inferior  nasal  concha  and  guarded 
by  a  valve  of  mucous  membrane  which  is  both  anatomically  and 


Clinical  Anatomy  of  the  Efferent  Lacrimal  Passageways       643 

physiologically  adequate  and  (5)  those  located  as  above  in  the  mucous 
membrane  of  the  lateral  wall  of  the  inferior  nasal  meatus  and  have  a 
valve  of  mucous  membrane,  but  which  from  the  viewpoint  of  physiol- 
ogy is  inadequate. 

It  is  certain  that  many  children  are  born  with  atresia  of  the  nasal 
end  of  the  nasolacrimal  duct,  owing  to  an  intact  or  imperforate  lacri- 
monasal  membrane.  It  also  is  equally  certain  that  a  goodly  number 


a  b 

Fig.  8. — a,  Type  of  nasolacrimal  ostium  located  in  the  mucous  membrane  of 
the  lateral  wall  of  the  inferior  nasal  meatus  considerably  below  the  highest  point 
of  the  latter.  Apertures  in  this  position  and  of  this  nature  are  readily  influenced 
by  intranasal  conditions.  Note  the  valve-like  folds  guarding  the  slit-like  orifice. 
Adult,  b,  Type  of  nasolacrimal  ostium  located  at  the  highest  point  of  the  inferior 
nasal  meatus,  supported  by  an  osseous  ring  and  standing  permanently  open, 
unguarded  by  a  mucosal  valve.  Adult. 


of  these  persistent  lacrimonasal  membranes  become  attenuated  and 
rupture  spontaneously  during  the  early  weeks  or  months  of  infantile 
life.  Indeed,  at  times  it  occurs  much  later.  Of  course,  where  the 
lacrimonasal  membrane  as  such  never  formed;  that  is,  where  a  goodly 
amount  of  connective  tissue  (of  mesenchymal  origin)  persists  between 
the  epithelium  of  the  nasolacrimal  duct  and  the  mucous  membrane 
of  the  inferior  nasal  meatus,  the  barrier  may  be  too  thick  for  spon- 


644  J.  PARSONS  SCHAEFFER 

taneous  rupture  and  surgical  procedures  often  are  necessary.  This 
also  is  true  in  some  instances  of  typical  lacrimonasal  membranes  which 
are  relatively  thin,  but  for  some  reason  or  other  do  not  "give  way."1 
Again,  epithelial  debris  may  act  as  an  occluding  plug.  Moreover, 
there  is  some  ground  for  believing  that  previously  established  lacrimo- 
nasal communications  occasionally  become  occluded  secondarily  by 
epithelial  proliferation.  Analogous  processes  occur  elsewhere  in  the 
body;  e.g.,  the  duodenum  and  the  nares. 

The  nasolacrimal  ostium  when  of  microscopic  size  usually  requires 
surgical  attention.  The  small  aperture  may  be  the  result  of  inade- 
quate canalization  or  undue  encroachment  of  the  surrounding  bone 
as  it  ossifies  around  the  early  nasolacrimal  duct  in  the  formation  of 
the  nasolacrimal  canal.  Not  infrequently  these  small  nasolacrimal 
ostia  are  located  at  the  highest  point  of  the  inferior  nasal  meatus. 
Again,  they  may  be  located  at  a  lower  level  in  the  mucosa  of  the 
lateral  wall  of  the  meatus. 

There  can  be  no  doubt  that  the  connection  of  the  nasolacrimal  duct 
with  the  inferior  nasal  meatus  serves  as  a  means  whereby  infection  of 
the  nasal  fossa  can  extend  into  the  nasolacrimal  apparatus.  Obvi- 
ously the  type  of  nasolacrimal  ostium  influences  the  incidence  of 
occurrence  of  such  extension  and  when  once  established  the  prognosis 
of  speedy  or  delayed  cure.  When  the  nasolacrimal  ostium  is  located 
high  and  supported  by  an  osseous  ring,  causing  it  to  stand  widely  and 
permanently  open  and  unguarded  by  a  valve  of  mucous  membrane, 
it  is  possible  for  infectious  air  and  fluids  to  pass  into  the  naso- 
lacrimal duct  and  from  there  into  the  lacrimal  sac.  Blowing  of  the 
nose  in  these  cases  readily  drives  particles  of  foreign  material  through 
the  open  and  unguarded  ostium  into  the  duct  and  the  sac  beyond. 
Tobacco  snuff  has  been  known  to  ascend  to  the  lacrimal  puncta  and 
cigar  and  cigarette  smoke  to  make  its  escape  from  these  apertures  on 
the  free  border  of  the  eyelids.  The  writer  observed  in  a  patient  with  a 
depressed  fracture  of  the  ventral  or  facial  wall  of  the  maxilla,  hemor- 
rhage from  both  lacrimal  puncta.  The  nasolacrimal  canal  and  the 
contained  duct  in  the  medial  or  nasal  wall  of  the  maxilla  must  have 
been  injured.  Fein  reports  a  case  of  air  escaping  from  the  lacrimal 
puncta  in  which  the  nasolacrimal  duct  was  injured  in  perforating  the 

1  For  an  interesting  and  valuable  clinical  paper  see  William  Zentmayer,  Im- 
perf  oration  of  the  Lacrimonasal  Duct  in  the  Newborn  and  its  Clinical  Manifesta- 
tions, Jour.  Amer,  Med.  Assoc.,  vol.  li,  1908. 


Clinical  Anatomy  of  the  Efferent  Lacrimal  Passageways       645 

maxillary  sinus.     It  also  has  been  observed  in  some  cases  of  nose 
bleeding  that  blood  escapes  from  the  lacrimal  puncta. 

The  same  regurgitation  of  air  and  fluids  from  the  inferior  nasal 
meatus  into  the  nasolacrimal  duct  may  be  argued  when  the  ostium 
lacrimale  is  located  in  the  mucosa  of  the  lateral  wall  of  the  inferior 
meatus  and  has  an  anatomic  valve  but  which  is  physiologically  inade- 
quate or  insufficient.  There  is,  however,  a  basic  difference,  since 
ostia  in  this  position  are  not  supported  by  osseous  boundaries ;  more- 
over, the  nasal  end  of  the  nasolacrimal  duct  courses  for  some  distance 
in  the  nasal  mucosa.  Increased  intranasal  pressure  would  tend  to 


Fig.  9. — A  section  through  the  nasolacrimal  ostium.  Particularly  note  the 
cavernous  or  erectile  character  of  the  mucous  membrane  forming  it  and  that  it  is 
not  unlike  the  erectile  tissue  of  the  inferior  concha  adjacent  to  it. 

collapse  not  only  the  nasolacrimal  aperture,  but  the  nasal  end  of  the 
membranous  duct  as  well,  while  the  cases  in  which  the  nasolacrimal 
aperture  is  supported  by  bone  and  no  membranous  segment  of  the 
duct  exists,  would  not  be  similarly  influenced. 

In  such  cases  where  the  fold  of  mucous  membrane  at  the  outlet  of 
the  nasolacrimal  duct  is  redundant,  it  not  only  may  serve  as  an  ana- 
tomic valve,  but  from  the  physiologic  point  of  view  be  sufficient  to 
prevent  the  regurgitation  or  passage  of  air  and  fluid  from  the  nose  into 
the  nasolacrimal  duct.  It  also  may,  to  some  degree,  serve  as  a  barrier 
to  the  extension  of  diseased  processes  from  the  nose  to  the  nasolacrimal 


646  J.  PARSONS  SCHAEFFER 

apparatus.  However,  disease  processes  affecting  the  mucosa  of  the 
nose  may  extend  into  the  nasolacrimal  duct  and  sac  despite  the  type 
of  ostium,  owing  to  the  continuity  of  the  mucous  membranes,  tissue 
spaces,  etc. 

It  is  but  necessary  to  recall  the  location  of  the  nasolacrimal  ostium 
to  comprehend  why  the  aperture  may  be  occluded  by  definite  me- 
chanical and  pathologic  states  of  the  nose.  Here  again  the  type  of 
ostium  plays  a  conspicuous  role.  Hypertrophy  of  the  inferior  nasal 
concha  may  wholly  or  partially  occlude  the  opening;  the  type  sup- 
ported by  an  osseous  ring  being  less  influenced  than  the  one  located 
in  the  mucous  membrane  of  the  lateral  nasal  wall  and  without  bony 
support.  Periostitis  would  affect  the  open-mouthed  type  of  ostium 
and  the  duct  in  the  neighborhood,  but  would  not  influence  the  actual 
ostium  if  located  in  the  mucous  membrane  of  the  lateral  wall  some 
distance  below  the  attached  border  of  the  inferior  concha.  Tumors, 
polypi,  dental  cysts,  synechia?,  rhinoscleroma,  etc.,  etc.,  readily  influ- 
ence the  efficiency  of  the  nasal  outlet  of  the  nasolacrimal  duct. 

It  also  is  important  to  recall  that  the  mucous  membrane  of  the 
inferior  nasal  concha  and  the  related  lateral  nasal  wall  and  the  ostium 
of  the  nasolacrimal  duct  frequently  is  of  an  erectile  character.  A 
mucosa  of  this  sort  is  readily  influenced  reflexly  and  directly  by  dis- 
eased states. 

DISCUSSION 

The  origin  and  development  of  the  efferent  lacrimal  passageways 
point  the  way  to  a  better  understanding  of  the  congenital  variations 
and  defects.  A  knowledge  of  the  developmental  history  and  poten- 
tialities is  a  distinct  aid  in  deciding  upon  the  course  of  the  treatment 
in  the  several  types  of  congenitally  atypical  ducts. 

Fortunately  the  development  of  the  efferent  lacrimal  or  naso- 
lacrimal passageways  (lacrimal  ducts,  lacrimal  sac,  nasolacrimal 
duct)  usually  proceeds  along  methodical  rather  than  fortuitous  lines. 
Despite  the  general  truth  of  the  foregoing  it  does  not  necessarily  mean 
a  constant  and  unvarying  anatomy  in  the  adult;  variations  in  essen- 
tial details  are  not  uncommon.  The  more  important  variations  are 
subject  to  grouping  into  normal  anatomic  types  and  it  is  the  thought 
of  anatomic  types  arid  anomalies  rather  than  the  idea  of  an  unvarying 
typical  anatomy  and  anomalies  that  should  be  kept  in  mind  when 
considering  the  applied  or  clinical  anatomy  of  the  efferent  tear  ducts. 

There  can  be  no  doubt  that  the  important  anatomic  types  or  de- 
partures from  the  so-called  typical  have  a  bearing  in  disease,  prog- 


Clinical  Anatomy  of  the  Efferent  Lacrimal  Passageways       647 

nosis  and  treatment.  Once  infected  arxd  other  factors  being  equal, 
it  would  appear  established  from  an  anatomic  point  of  view  that  the 
lacrimal  sac  and  the  nasolacrimal  duct  free  of  mucosal  ledges,  valve- 


a  b 

Fig.  10. — a,  A  nasolacrimal  duct  (adult)  with  an  unusually  large,  blindly 
ending  diverticulum;  b,  a  transaction  of  an  adult  nasolacrimal  duct  in  the  region 
of  a  goodly  sized  diverticulum. 

like  formations  and  blindly  ending  diverticula;  moreover,  with  a 
large  open-mouthed  and  unobstructed  connection  with  the  inferior 
nasal  meatus  would  give  rise  to  less  severe  symptoms  and  yield  more 


648  J.  PARSONS  SCHAEFFER 

readily  and  promptly  to  treatment;  while  the  passageways  with 
irregular  walls,  mucosal  ledges  and  valves,  diverticula  of  various 
degrees  and  an  inadequate  nasal  communication  would  give  rise  to 
maximum  symptoms,  resist  treatment,  enter  the  stage  of  chronicity 
and,  in  all  likelihood,  require  surgical  interference.  Granting  the  same 
type  of  infection  and  degree  of  involvement,  the  prognosis  for  a  speedy 
and  permanent  cure  in  the  two  types  of  the  efferent  lacrimal  apparatus 
is  not  the  same.  Not  all  of  the  anatomic  factors  mentioned  neces- 
sarily need  apply  in  one  patient.  The  prognosis  may  rest  entirely 
in  the  adequacy  or  inadequacy  of  the  nasolacrimal  ostium  in  the 
inferior  nasal  meatus  as  a  drainage  aperture.  Again,  diverticula 
alone  may  be  the  factor  or  the  junction  of  the  lacrimal  sac  with  the 
nasolacrimal  duct  may  be  congenitally  of  extremely  small  size,  et 
cetera. 

The  extension  of  disease  processes  from  the  nasal  fossa  and  the 
paranasal  sinuses  to  the  efferent  lacrimal  passageways  is  of  common 
occurrence  and  generally  recognized.  This  is  in  keeping  with  the 
intimate  relational  anatomy.  The  incidence  of  nasal  and  paranasal 
disease,  however,  is  greater  than  secondary  disease  of  the  efferent 
lacrimal  apparatus.  The  extension  doubtless  is  dependent  upon  the 
nature,  severity  and  duration  of  the  pathologic  processes  within  the 
nose  and  paranasal  sinuses,  and  the  degree  of  intimacy  of  the  topo- 
graphic interrelations  of  the  several  parts  (see  the  nasolacrimal  ostium 
and  the  paranasal  sinuses,  etc.,  referred  to  before).  Of  course,  minor 
involvement  of  the  efferent  lacrimal  channels,  secondary  to  patho- 
logic states  within  the  nasal  fossa  and  the  related  sinuses  may  go 
unrecognized.  For  example,  epiphora  may  be  caused  by  a  mild 
infection  of  some  portion  of  the  mucosa  of  the  efferent  lacrimal 
channels  resulting  in  congestion  of  the  venous  plexus  of  the  lacrimal 
sac  and  the  nasolacrimal  duct  and  a  marked  lessening  of  the  lumen. 
It  is  difficult  to  decide  in  some  cases  whether  the  overflow  of  tears 
is  due  to  an  overproduction  or  to  an  inadequate  removal.  Probably 
both  are  factors,  since  the  nasal  state  may  reflexly  stimulate  the 
lacrimal  gland  to  greater  activity  and  affect  the  lumen  of  the  efferent 
system  of  ducts  by  bringing  about  hyperactivity  of  the  sphincter 
muscle  about  the  vertical  segment  of  the  lacrimal  ducts  and  a  reflex 
engorgement  of  the  venous  plexus  in  the  mucosa  of  the  sac  and  main 
duct.  However,  it  is  well  to  remember  that  epiphora  is  frequently 
caused  reflexly  by  diseased  foci  elsewhere  and  by  conditions  other 
than  obstruction  of  the  efferent  lacrimal  channels.  Operative  pro- 


Clinical  Anatomy  of  the  Efferent  Lacrimal  Passageways       649 


Fig.  11. — Reconstruction  of  the  naso- 
lacrimal passageways  of  an  adult,  aged 
sixty  years.  Note  the  regularity  of  the 
nasolacrimal  duct  and  the  gradual 
mergence  of  the  lacrimal  sac  into  the 
nasolacrimal  duct  at  the  constriction 
of  the  isthmus.  X  3.2.  Abbrevia- 
tions as  in  Fig.  12.  (Schaeffer:  The 
Nose  and  Olfactory  Organ.) 


Fig.  12. — Reconstruction  of  the 
nasolacrimal  passageways  of  an  adult, 
aged  sixty-five  years.  Especially  note 
the  irregularity  and  diverticula  of  the 
nasolacrimal  duct. 

The  inset  shows  the  details  of  the 
side-to-side  union  of  the  lacrimal  sac 
and  the  nasolacrimal  duct;  moreover, 
illustrates  the  large  bud-like  divertic- 
ulum  from  the  nasolacrimal  duct. 
X  3.2. 

SI,  Saccus  lacrimalis;  Dlv,  ductus 
lacrimalis  verticalis;  Dlh,  ductus  lacri- 
malis horizon talis;  Die,  ductus  lacri- 
malis communis;  Dnl,  ductus  naso- 
lacrimalis;  Mni,  meatus  nasi  inferior; 
Div'lm,  diverticulum  of  the  nasolacri- 
mal duct;  Jc,  junction  channel  be- 
tween the  lacrimal  sac  and  the  naso- 
lacrimal duct. 


650  J.  PARSONS  SCHAEFFEK 

cedures  should  be  held  in  abeyance  until  the  case  is  studied  from 
every  angle. 

Congenital  and  acquired  strictures,  imperforations  and  other  con- 
ditions are  encountered  and  the  use  of  the  lacrimal  probe  may  be 
indicated.1  The  lacrimal  puncta  may  need  adjustment  or  enlarge- 
ment. An  endonasal  operation  upon  the  nasolacrimal  duct  or  the 
lacrimal  sac  may  be  deemed  advisable,  the  type  of  operation  being 
dependent  upon  the  kind  and  position  of  the  obstruction.  The  only 
alternative  may  be  the  extirpation  of  the  lacrimal  sac  or  even  the 
lacrimal  gland.  However,  the  majority  of  cases  of  diseased  efferent 
lacrimal  passageways  require  less  severe  treatment,  frequently 
medical  rather  than  surgical.  In  directing  treatment  of  the  efferent 
lacrimal  apparatus  one  should  always  recall  a  few  salient  points  in 
the  applied  anatomy :  The  mucosa  of  the  lacrimal  sac  and  the  naso- 
lacrimal duct  between  the  tunica  propria  and  the  periosteum  is  richly 
supplied  with  a  venous  plexus  not  unlike  an  erectile  tissue.  This 
stratum  is  readily  engorged  directly  or  indirectly  and  the  resulting 
swelling  of  the  mucosa  is  at  the  expense  of  the  lumen  of  the  sac  and 
duct,  especially  the  latter,  since  it  is  encased  in  a  bony  canal.  The 
passageways  may  be  of  the  regular  or  irregular  type.  There  is  no 
actual  stricture  or  absolute  anatomic  obliteration  of  the  lumen. 
The  use  of  stilettes  and  cannulas  in  these  cases  would  appear  to 
stimulate  reflexly  further  engorgement,  and  the  good  to  be  derived 
to  be  but  momentary.  The  anatomy  and  physiology  are  such  that 
the  treatment  must  be  directed  at  the  agent  which  stimulates  the 
receptor  neuron  in  the  reflex  arc,  whether  located  in  the  mucosa  of 
the  lacrimal  passageways,  the  related  nose  and  paranasal  sinuses,  or 
at  more  remote  points. 

Again,  not  infrequently  the  lumen  of  the  lacrimal  sac  and  the 
nasolacrimal  duct  is  encroached  upon  and  made  irregular  by  mucosal 
ledges  and  partial  or  complete  valves  and  diverticula.  In  infection, 
the  swelling  and  engorgement  of  the  mucosa  in  these  cases  result 
even  in  a  greater  obstruction  to  the  flow  of  tears.  As  before  there  is 
no  actual  stricture  or  absolute  anatomic  obstruction  of  the  lumen. 

1  See  S.  Lewis  Ziegler  for  valuable  contributions  to  this  subject.  The  Radical 
Treatment  of  Lacrimonasal  Disease  by  Rapid  Dilatation  and  Allied  Measures, 
Jour.  A.  M.  A.,  Vol.  54,  1910.  Since  submitting  copy  of  this  address  the  writer 
had  the  privilege  of  reading  another  communication  by  Dr.  Ziegler,  "A  Further 
Note  on  Rapid  Dilatation  in  the  Radical  Treatment  of  Lacrimonasal  Disease," 
published  in  the  volume  of  papers  to  be  presented  before  the  Section  on  Ophthal- 
mology of  the  American  Medical  Association,  St.  Louis,  1922. 


Clinical  Anatomy  of  the  Efferent  Lacrimal  Passageways       651 

However,  the  obstruction  may  be  absolute  from  the  physiologic  point 
of  view.  The  advancing  lacrimal  probe  or  stilette,  doubtless,  would 
lacerate  the  mucosal  ledges  and  valves  and  scrape  the  mucous  mem- 
brane, which  would  aggravate  conditions.  One  sees  that  an  im- 
permeable stricture  might  result  from  this  procedure,  and  in  cases 
where  the  primary  condition  merely  was  a  reduction  of  the  lumen 
to  a  potential  canal  by  a  swollen  and  engorged  mucosa;  that  is,  a 
physiologic,  but  not  an  anatomic,  occlusion. 

The  majority  of  specimens  show  that  the  lacrimal  sac  and  the 
nasolacrimal  duct  are  in  direct  alignment  and  meet  each  other  by  a 
constriction  or  isthmus  or  imperceptibly  passing  one  into  the  other. 
A  probe  is  readily  passed  from  the  sac  into  the  duct  in  these  cases, 
unless  the  isthmus  is  unduly  small. 

Occasionally  the  lacrimal  sac  and  the  lacrimal  duct  are  not  in 
alignment  and  are  joined  side  by  side,  the  lower  end  of  the  lacrimal 
sac  extending  below  the  highest  point  reached  by  the  nasolacrimal 
duct.  In  such  cases  it  would  be  utterly  impossible  to  pass  the  lacri- 
mal probe  from  the  sac  into  the  duct  and  if  undue  force  were  used  the 
instrument  would  be  pushed  through  the  lower  blind  end  of  the 
lacrimal  sac  and  advance  between  the  nasolacrimal  duct  and  the 
osseous  canal,  again  to  be  pushed  back  into  the  membranous  pathway 
or  to  proceed  by  making  a  false  ostium  into  the  inferior  nasal  meatus. 

It  appears  certain  that  the  lower  aperture  of  the  nasolacrimal  duct 
is  a  factor  in  disease  and  treatment  and  that  it  should  receive  more 
attention  clinically.  It  may  invite  infection  of  the  efferent  lacrimal 
apparatus.  Again,  in  a  diseased  lacrimal  duct  and  sac,  the  naso- 
lacrimal ostium  may  be  wholly  inadequate  as  a  drainage  apparatus. 
Frequently  the  anatomy  is  such  that  a  simple  operation  would  result 
in  adequate  drainage  of  the  efferent  tear  ducts.  Even  troublesome 
and  unexplained  epiphora  may  be  caused  by  a  congenitally  inade- 
quate type  of  ostium  or  aperture. 

Heretofore  the  surgeon  did  not  know  what  anatomic  conformation 
of  the  efferent  lacrimal  passageways  confronted  him  in  a  specific 
case.  Now  that  roentgenographic  study  has  been  extended  to  in- 
clude the  efferent  lacrimal  passageways  in  the  living  body,  it  appears 
certain  that  the  future  treatment  and  surgery  of  these  structures  will 
be  advanced. 

I  now  return  to  my  original  thesis — the  anatomic  type  and  the 
variations  in  the  relational  anatomy  have  an  important  bearing  in 
disease,  treatment  and  prognosis. 


THE  FACTS  AND  THEORIES  OF  COLOR  VISION 

PROF.  LEONARD  THOMPSON  TROLAND 

Harvard  University 
Cambridge,  Mass. 

I.  INTRODUCTION 

Guessing  at  nature's  secrets  has  always  been  a  favorite  amusement 
of  the  human  mind,  but  in  no  department  of  thought  has  this  form  of 
diversion  been  so  wantonly  pursued  as  in  the  theory  of  color  vision. 
Only  in  the  domain  of  metaphysics  have  the  guesses  been  more  wild 
or  untamed  by  the  facts.  I  cannot  hope  in  the  brief  time  which  has 
been  allotted  to  me  to  review  the  multitudinous  speculations  which 
have  appeared  regarding  the  basis  of  color  vision,  and  it  would  be 
impossible  also  to  discuss  in  detail  the  relations  existing  between  even 
one  of  these  speculations  and  all  of  the  facts  in  the  case.  I  shall, 
therefore,  confine  myself  to  a  more  general  theme,  mentioning  particu- 
lar theories  or  facts  merely  by  way  of  illustration.  This  theme  will  be 
to  outline  the  requirements  which  must  be  satisfied  by  a  really  accept- 
able hypothesis,  one  which  will  not  be  merely  a  wild,  unbridled  specu- 
lation, but  which  will  seem  at  home  in  the  company  of  all  of  the  facts. 

The  study  of  color  vision  leads  one  immediately  into  three  seemingly 
separate  domains  of  scientific  thought,  those  of  physics,  physiology 
and  psychology.  Color  itself,  apart  from  its  stimulus,  is  now  generally 
conceded  by  physicists,  as  well  as  by  philosophers,  to  be  psychologic 
in  character.  It  is  a  reality  of  immediate  experience  or  of  the  indi- 
vidual consciousness  merely.  In  and  for  itself  color  must  be  studied 
by  the  methods  of  mental  science  since  it  proves  impossible  to  identify 
color  either  with  the  wave-lengths  of  radiant  energy  or  with  physio- 
logic activities  in  the  nervous  system.  However,  it  is  very  evident 
that  the  knowledge  of  color  vision  cannot  stop  where  introspective 
psychology  stops.  Color  would  be  color  if  we  knew  nothing  of  phy- 
siology or  of  physics,  but  it  would  not  be  vision.  We  must  not  only 
recognize  the  nature  and  relationships  of  our  visual  sensations  in  and 
among  themselves,  but  we  must  understand  how  they  are  related 
psychophysically  to  the  processes  of  the  living  nervous  system  and  via 

652 


The  Facts  and  Theories  of  Color  Vision  653 

these  with  the  factors  of  the  physical  environment  which  surrounds 
the  organism.  Thus  we  are  brought  face  to  face  with  problems  not 
only  in  psychology  but  in  physiology  and  physics. 

The  vast  multitude  of  extant  color  theories  have  been  propounded 
by  thinkers  within  all  three  of  the  just  mentioned  domains  of  science 
as  well  as  by  others  whose  domains  have  not  been  scientific  at  all. 
Nearly  every  available  psychologic,  physiologic,  or  physical  idea  has 
been  utilized.  To  explain  the  selectivity  of  the  retinal  response, 
recourse  has  been  had  to  every  known  property  of  radiant  energy. 
The  mechanism  of  the  retina  itself  has  been  conceived  mechanically, 
chemically,  and  electrically.  Neurologic  conceptions  of  all  sorts  have 
been  applied  or  invented.  The  optic  nerve  currents  have  been  sub- 
divided or  combined,  in  the  course  of  conduction  or  at  the  brain,  in  a 
kaleidoscopic  variety  of  hypothetic  patterns.  Within  conscious- 
ness itself  colors  have  been  classified  in  many  different  ways.  Nearly 
a  hundred  major  attempts  at  an  explanation  of  the  phenomena  of 
color  vision  have  appeared  in  the  nineteenth  and  twentieth  centuries. 
Out  of  such  a  host  of  trials  we  might  expect  to  find  something  besides 
errors.  Our  hopes,  however,  are  so  poorly  fulfilled  that  it  seems 
pertinent  to  consider  briefly  what  Mrs.  Ladd-Franklin  has  aptly 
called  the  theory  of  color  theories. 

II.     THE  GENERAL  FACTS  OF  COLOR  VISION 

It  will  be  generally  conceded  that  the  task  of  science  is  restricted  to 
giving  an  account  of  what  exists  or  what  may  reasonably  be  supposed 
to  exist.  If,  therefore,  we  should  assert  that  the  function  of  a  color 
theory  is  to  explain  the  facts  of  color  vision,  we  would  be  obliged  to 
interpret  this  as  meaning  that  the  theory  supplements  the  facts  in 
the  direction  of  a  more  complete  account  of  the  system  which  is  under 
consideration.  An  hypothesis  concerning  the  mechanism  of  color 
vision  cannot  legitimately  be  regarded  as  being  merely  a  pedagogic 
or  mnemonic  device.  However  much  it  may  assist  us  in  teaching  or 
in  remembering  the  facts  of  our  science,  if  we  are  to  consider  it  seri- 
ously we  must  look  upon  it  as  a  representation  of  some  kind  of  reality. 
A  scientific  hypothesis  is  an  attempt,  so  to  speak,  to  project  the  facts 
beyond  themselves,  to  reach  out  into  the  as  yet  undiscovered  domain, 
to  prophesy  the  facts  of  the  future.  In  so  far  as  an  hypothesis  is 
valid,  in  so  far  is  it  liable  to  become  in  time  a  fact  and  not  a  fancy. 

When  we  say  that  an  hypothesis  or  a  theory  should  explain  the 
known  facts,  we  merely  mean  that  it  should  combine  with  these  facts 


654  LEONARD  THOMPSON  TROLAND 

in  such  a  way  as  to  produce  a  logically  coherent  account  of  things. 
The  reason  why  we  need  to  advance  hypotheses  lies  exactly  in  the 
truth  that  in  nearly  every  department  of  science  the  facts  which  we 
possess  do  not  in  themselves  form  a  coherent  logical  system.  How- 
ever, the  more  facts  we  have  in  any  science  the  more  coherent  the 
science  becomes,  and  consequently  we  believe  that  a  complete  under- 
standing of  any  reality  will  always  yield  such  a  logically  satisfactory 
account.  This  is  why  we  are  justified  in  using  our  imaginations  to 
fill  in  the  gaps  between  the  facts,  even  when  these  gaps  are  so  large  as 
to  leave  relatively  little  indication  of  the  real  underlying  order  which 
is  involved.  Our  actual  data  in  such  a  field  of  investigation  as  that  of 
color  vision  are  like  scraps  of  a  chopped-up  picture  puzzle,  most  of 
the  pieces  of  which  have  been  lost.  However,  enough  may  be  given 
so  that  we  have  some  chance  of  reconstructing  the  whole  in  imagina- 
tion. It  must  be  realized,  however,  that  the  fewer  the  parts  or  the 
facts  at  hand,  the  lower  is  the  probability  that  our  reconstruction  will 
be  correct. 

These  considerations  should  indicate  to  us  clearly  both  the  nature 
of  our  problem  and  the  method  which  we  must  employ  in  its  at- 
tempted solution.  A  theory  of  color  vision  is  a  picture  of  reality  which 
must  be  set  harmoniously  in  the  frame  of  facts.  In  order  to  evaluate 
any  such  theory  we  must  view  it  within  this  frame,  and  since  the 
frame  of  facts  is  a  definite  thing  and  the  possible  pictures  many  and 
shifting,  we  shall  do  well  to  study  briefly  the  former  before  we  con- 
sider the  latter  in  any  detail.  In  outlining  the  facts  which  any  theory 
of  color  vision  must  satisfy  I  shall  divide  them  into  two  classes,  as  the 
general  and  the  special  facts  respectively.  The  general  facts  comprise 
the  established  principles  of  physics,  physiology,  psychology  and 
psychophysiology  which  inevitably  bear  upon  the  problem.  The 
special  facts  consist  of  the  more  or  less  scattered  data  which  have 
thus  far  been  gathered  in  the  immediate  study  of  color  vision  itself. 

Let  us  first  consider  some  of  the  more  important  of  the  general 
principles  which  are  involved  in  the  situation.  These  principles  can 
be  divided  systematically  into  the  physical,  the  psychologic  and  the 
psychophysical  respectively.  Under  the  first  will  be  included  not  only 
the  conceptions  of  physical  optics  but  also  those  of  physiology,  since 
physiology  can  be  classed  as  a  special  physical  science  dealing  with  the 
properties  of  particularly  complex  material  structures  called  living 
organisms.  The  psychologic  principles  relate  to  experience  or  con- 
sciousness in  itself,  without  reference  to  any  supposed  physiologic  or 


The  Facts  and  Theories  of  Color  Vision  655 

other  physical  foundations  or  correlatives  which  it  may  possess.  The 
psychophysical  principles,  in  turn,  involve  the  relation  between  con- 
sciousness and  the  physical  system. 

If  we  look  first  at  the  physical  side  of  the  problem  we  find  that  we 
have  to  deal  in  vision  with  a  mechanism  which  in  its  general  outlines 
is  capable  of  being  very  specifically  defined.  This  mechanism  we 
may  designate  as  that  of  visual  response,  while  recognizing  that  the 
meaning  which  we  shall  assign  to  the  term  response  in  this  connection 
is  somewhat  broader  than  that  which  is  usually  given  to  it.  Visual 
response  is  one  example  of  a  general  type  of  physical  process  known 
as  propagation.  Other  examples  of  propagation  are  to  be  found  in 
sound,  in  the  conduction  of  electricity  through  a  wire,  or  of  water 
through  pipes,  etc.  In  each  of  these  processes  there  is  involved  a  chain 
of  events  depending  one  upon  another  in  serial  order,  corresponding 
events,  or  events  ultimately  traceable  to  the  same  initial  cause,  being 
displaced  successively  both  in  space  and  in  time.  In  the  case  of 
visual  response  the  initial  event  may  be  conceived  to  lie  in  the  emis- 
sion or  the  reflection  of  visible  radiant  energy  from  a  physical  object, 
while  the  final  result  may  be  laid  in  some  adaptive  adjustment  of  the 
organism  to  its  environment,  such  as  a  movement  of  the  eyes  or  of 
some  other  member  of  the  body.  Between  such  initial  and  final 
events,  and  binding  them  together  causally,  there  lie  a  considerable 
number  of  intermediate  stages.  A  schematic  analysis  of  the  response 
from  beginning  to  end  would  reveal  the  following  successive  stages : 
(1)  the  object,  (2)  the  visual  stimulus,  (3)  the  visual  sense-organ 
process,  (4)  the  retinal  or  visual-receptor  process,  (5)  the  optic  nerve 
stimulation,  (6)  the  optic  nerve,  or  afferent  nerve  conduction,  (7)  the 
central  or  adjuster  process,  (8)  the  efferent  nerve  conduction,  (9)  the 
end-plate  process,  (10)  the  effector  process,  (11)  the  effect. 

All  of  these  component  processes  are  linked  together  as  cause  to 
effect,  although  at  the  same  time  each  one  possesses  its  own  charac- 
teristics which  make  its  description  different  from  those  of  either  its 
cause  or  its  own  effects.  Thus,  the  retinal  reaction  is  governed  by 
the  exact  manner  in  which  the  radiation  is  incident  upon  the  retina 
in  forming  the  retinal  image,  and  yet  must  be  conceived  to  differ 
radically  from  the  radiation  itself.  At  the  same  time  we  must 
recognize  that  those  links  in  the  response  chain  which  lie  within  the 
organism  are  ultimately  just  as  physical  as  are  those  which  lie  outside 
of  it,  the  entire  system  forming  a  continuous  physical  mechanism  all 
of  which  is  ultimately  reducible  to  terms  of  such  fundamental  units 


656  LEONARD  THOMPSON  TROLAND 

as  electricity  and  energy.  Nowhere  within  this  complex  physical 
apparatus'do  we  find,  nor  do  we  need  to  assume,  the  existence  of  such 
a  thing  as  sensation,  and  hence  as  color.  Let  us  consider  briefly  some 
of  the  known  specific  characteristics  of  these  several  stages  in  the 
visual  response. 

The  first  stage,  the  visible  object,  consists  of  any  congeries  of 
electrons  and  protons  constituting  a  physical  body,  some  of  the  elec- 
trical particles  in  the  surface  of  which  are  vibrating  at  frequencies 
lying  between  about  715  and  440  trillion  oscillations  per  second. 
Such  oscillations  set  up  electromagnetic  waves  of  lengths  lying  be- 
tween approximately  420  and  680  millimicrons  which  travel  radially 
away  from  their  sources  at  the  rate  of  186,000  miles  a  second.  Before 
the  advent  of  Einstein  we  used  to  believe  that  these  waves  were  undula- 
tions in  a  medium  called  the  ether,  but  now  we  are  content  to  say 
simply  that  they  are  electromagnetic  in  character,  which  does  not 
prevent  them  from  being  waves  although  they  are  seemingly  deprived 
of  anything  in  which  to  undulate.  When  such  waves  impinge  upon 
the  cornea  they  are  refracted  from  their  normally  rectilinear  path  so 
that,  after  suffering  further  convergence  in  passing  through  the  crys- 
talline lens,  they  come  to  a  focus  upon  the  retina  to  form  a  pattern 
roughly  similar  to  that  which  they  possessed  at  the  object.  Thus  far 
we  are  carried  very  securely  by  our  knowledge  of  physical  optics  and 
the  anatomy  of  the  eye,  but  here  our  knowledge  comes  abruptly  to  a 
chasm. 

The  fourth  stage,  the  retinal  receptor  process,  is  known  to  exist  as  a 
fact  but  its  specific  nature  is  as  a  fact  unknown.  Consequently  this 
stage  becomes  a  subject  of  hypothesis  and  speculation.  Similar 
statements  apply  to  the  fifth  stage,  or  the  process  by  which  the  retinal 
excitation  is  transformed  into  a  nerve  impulse.  When  we  come  to  the 
sixth  stage,  however,  the  conduction  along  the  optic  nerve  fibers,  we 
are  in  a  somewhat  better  position.  We  can  detect  and  accurately 
measure  these  nerve  currents  in  animals  by  means  of  a  galvanometer, 
and  modern  studies  upon  nerve  processes  in  general  lead  us  to  very 
definite  conceptions  as  to  the  physical  nature  of  such  processes. 
There  is  no  reason  to  suppose  that  the  human  optic  nerve  currents 
form  exceptions  to  these  generally  established  principles.  The  nerve 
current,  as  we  now  conceive  it,  consists  of  a  series  of  so-called  "all-or- 
none"  pulses,  each  of  which  involves  a  local  alteration  of  the  electric 
polarization  and  chemic  permeability  of  the  membrane  surrounding 
the  nerve  cell. 


The  Facts  and  Theories  of  Color  Vision  657 

We  find  that  the  seventh  or  central  stage  in  the  response  propaga- 
tion has  many  representatives  in  the  case  of  vision,  since  the  transfer 
of  visual  nerve  currents  from  sensory  to  motor  channels  may  take 
place  at  a  number  of  different  brain  levels,  and  a  succession  of  synapses 
is  involved  in  the  transmission  of  the  nerve  impulses  to  the  very 
highest  centers  in  the  cerebral  cortex.  Although  we  have  very  little 
first-hand  information  concerning  the  physical  nature  of  the  central 
processes,  fairly  safe  inferences  can  be  made  regarding  them  from  a 
combination  of  our  knowledge  of  plain  nerve  trunk  conduction,  and 
conduction  through  entire  reflex  arcs.  The  differences  between  these 
two  types  of  neural  transfer  have  been  properly  assigned  by  Sher- 
rington  to  the  synapse.  The  four  efferent  or  motor  stages  in  visual 
response  are  also  quite  diverse  in  separate  instances.  We  must 
recognize  in  this  connection,  not  only  the  motor  adjustments  of  the 
eyes  themselves,  highly  specific  and  delicate  as  these  truly  are,  but 
also  all  adaptive  movements  of  any  part  of  the  organism  which  are 
regulated  through  vision. 

So  much  for  the  general  frame  of  physical  or  physiologic  concep- 
tions into  which  our  pictorial  hypotheses  of  the  color  mechanism  must 
fit.  We  must  now  consider  briefly  another  aspect  of  the  frame,  the 
psychologic  decorations  with  which  it  is  embellished,  and  the  manner 
in  which  they  are  associated  psychophysically  with  its  more  material 
aspects.  The  subject-matter  of  modern  psychology  is  consciousness 
and  its  relations  to  the  physical  world,  and  consciousness  for  the  modern 
psychologist  is  not  some  sort  of  subtle  relation  between  a  subject  and 
an  object,  but  consists  simply  in  the  concrete  experiences  of  human 
individuals,  taken  and  described  exactly  as  they  are  found  without 
amplification  by  the  methods  of  speculative  inference  and  hypothesis 
which  characterize  physical  thought.  Our  immediate  visual  experi- 
ences, objective-seeming  though  they  are,  comprise  the  best  possible 
exemplification  of  what  modern  psychology  means  by  consciousness. 
Color,  whether  chromatic  or  achromatic,  is  a  psychical  element  and  a 
psychical  element  only.  It  cannot  be  identified  in  any  respect  with 
its  stimulus,  radiant  energy.  The  stimulus,  according  to  the  phy- 
sicist, is  endowed  with  wave-length,  amplitude  and  spectral  com- 
plexity, and  it  has  no  color,  but  the  color  itself  is  self-evidently 
neither  long  nor  wavy,  has  no  amplitude,  and  is  perfectly  simple. 

Having  thus  identified  color  as  an  essential  component  of  the  visual 
consciousness,  we  must  next  consider  the  manner  in  which  this  con- 
sciousness is  related  to  visual  response.  There  are  two  apparent 
42 


658          LEONARD  THOMPSON  TROLAND 

ways  in  which  we  may  conceive  these  two  separately  denned  systems 
to  be  associated.  One  of  these  ways  involves  the  question  as  to  the 
place  of  consciousness  in  the  universe  at  large,  as  to  the  manner  in 
which  the  physical  and  the  psychologic  facts  fit  together  to  form  a 
single  huge  mosaic.  This  is  clearly  a  philosophic  and  metaphysical 
question.  The  other  way  is  simply  that  of  association  through  mathe- 
matic  or  logically  formal  laws.  Such  laws  would  tell  us  how  to  predict 
the  visual  consciousness  from  a  knowledge  of  the  visual  response,  or 
vice  versa,  since  they  would  exhibit  one  of  these  systems  as  a  function 
of  the  other,  but  they  would  in  themselves  offer  no  explanation  of  the 
indicated  interdependencies.  The  metaphysical  account,  indeed,  is 
really  an  attempt  to  explain  the  psychophysical  laws  which  are 
established  by  the  empirical  methods  of  laboratory  psychology. 

Psychophysiology  has  only  begun  its  task  of  determining  the  laws 
which  link  the  visual  consciousness  with  the  mechanism  of  visual 
response.  However,  enough  progress  has  been  made  to  indicate  in  a 
skeletal  way  the  principal  facts  which  probably  enter  into  the  rela- 
tionship. It  seems  quite  evident  in  the  first  place  that  although  our 
visual  experiences  seem  to  represent  the  first,  or  object,  stage  in  the 
response,  their  direct  determination  lies  exclusively  with  the  highest 
central  stage  or  the  cerebrocortical  activities.  Only  via  the  depen- 
dency of  the  central  stages  upon  prior  and  more  afferent  stages  is  any 
relationship  established  between  visual  experience  and  the  object  or 
stimulus  which  initiates  the  response.  If  we  could  reproduce  the 
central  activities  by  artificial  means  and  could  then  eliminate  the 
entire  afferent  system,  consciousness  would  remain  exactly  as  before — 
just  as  vivid  and  exactly  as  objective-seeming. 

Ultimate  visual  psychophysics,  then,  would  involve  nothing  but 
consciousness  and  the  brain  process,  the  remainder  of  the  system 
being  purely  physiologic  or  physical.  Unfortunately,  however,  we 
are  still  very  far  from  achieving  such  an  ultimate  knowledge  and  we 
are,  therefore,  forced  to  study,  in  the  laboratory  or  clinic,  the  relations 
between  the  subject's  consciousness  and  stages  of  the  response  which 
are,  as  a  rule,  more  peripheral  than  the  central  activity.  In  all  such 
cases  we  are  clearly  considering  indirect  or  mediate  psychophysical 
linkages,  and  we  must  realize  that  all  such  linkages  are  subject  to 
physiologic  disturbances.  It  is  very  probable  that  visual  conscious- 
ness actually  depends  upon  activities  occurring  in  some  of  the  very 
highest  association  areas  of  the  cerebral  cortex,  so  that  even  the  estab- 
lishment of  correlations  between  consciousness  and  the  visual  pro- 


The  Facts  and  Theories  of  Color  Vision  659 

jection  area  processes  does  not  provide  us  with  direct  psychophysical 
knowledge.  The  most  extensively  cultivated  department  of  visual 
psychophysiology  is  that  of  visual  sensation,  which  may  be  denned  in 
terms  of  the  relation  of  dependency  obtaining  between  the  visual 
consciousness  and  the  first  four  stages  in  the  response,  terminating 
in  the  receptor  process,  but  including  the  environmental  forces  which 
govern  this  process  in  part. 

Although  it  seems  practically  certain  that  the  general  facts  of  the 
psychophysical  relationship  are  as  we  have  described  them  above, 
we  are  nevertheless  sadly  lacking  in  exact  information  concerning  the 
detailed  nature  of  the  psychophysical  correlations.  Consciousness 
itself  is  wide  open  for  our  examination,  and  introspective  psychology 
is  doing  its  best  to  give  us  a  description  of  its  contents.  Because  of 
the  fact,  however,  that  up  to  the  present  time  our  psychophysical 
investigations  have  been  largely  confined  to  indirect  relationships 
between  consciousness  and  the  response  activity,  we  are  not  in  a 
position  to  formulate  on  empirical  grounds  the  equations  which  con- 
nect mind  directly  with  body.  Hence  the  psychophysical  connection 
is  another  free  and  fertile  field  in  which  to  sow  the  seeds  of  scientific 
hypothesis. 

It  is  clear  that  the  rational  guesses  which  comprise  a  theory  of  color 
vision  must  be  consistent  with  the  general  principles  which  we  have 
just  considered  if  they  are  to  be  regarded  seriously.  Any  such  theory 
must  recognize  the  extreme  complexity  of  the  visual  response  system 
and  must  be  prepared  to  specify  the  relationships  supposed  to  exist 
between  the  elements  in  the  theory  and  the  known  subdivisions  of  the 
response.  Any  theory  of  color  vision  must  deal ^ separately  with  the 
data  of  consciousness  and  must  specify  a  scheme  by  which  the  psy- 
chologic color  elements  are  associated  with  definite  factors  in  the 
response.  Unless  the  color  theorist  thus  envisages  the  actual  system 
to  which  his  speculations  refer,  he  has  small  chance  of  producing  a 
valid  or  even  a  useful  sketch. 

III.    THE  SPECIAL  FACTS  OF  COLOR  VISION 

It  appears  that  a  theory  or  hypothesis  of  color  vision  may  be 
regarded  as  an  attempt  to  fill  up  the  gaps  which  exist  in  our  general 
knowledge  of  the  psychophysical  response  mechanisms ;  and  in  such  a 
way  as  to  explain  or  to  harmonize  with  our  special  knowledge  of 
visual  psychophysiology.  Having  briefly  reviewed  the  general  facts, 


660  LEONARD  THOMPSON  TROLAND 

we  must  now  consider  succinctly  the  special  visual  data,  mostly 
relating  to  color  sensation,  which  any  theory  must  satisfy. 

The  first  set  of  special  facts  which  we  must  recognize  are  concerned 
with  the  nature  of  color  itself.  The  Colorimetry  Committee  of  the 
Optical  Society  of  America,  in  its  forthcoming  report,  will  recommend 
that  the  term  color  be  used  to  designate  not  only  visual  sensations 
which  manifest  hue,  such  as  red,  green,  blue,  etc.,  but  also  the  achro- 
matic sensations  or  grays  which  form  a  series  between  black  and 
white.  Colors  in  this  sense  comprise  all  possible  visual  experiences 
with  the  exception  of  the  depth  factor.  Although  each  discrimin- 
able  color  is  in  itself  perfectly  simple,  we  find  it  possible  to  describe 
any  color  in  terms  of  three  attributes,  technically  known  as  hue, 
saturation,  and  brilliance.  The  achromatic  colors,  however,  possess 
no  hue  and  no  saturation  and  are  differentiated  solely  by  their  differ- 
ences in  brilliance. 

The  facts  regarding  visual  sensation  can  be  formulated  in  terms  of 
relations  between  these  three  attributes  of  color  and  various  factors 
of  the  response  mechanism  on  the  afferent  side.  We  find  that  char- 
acteristic laws  connect  each  of  the  three  attributes  with  practically 
every  variable  which  is  involved  in  the  response.  Ordinarily  we 
associate  brilliance  or  apparent  brightness  with  the  intensity  of  the 
stimulus.  We  look  upon  hue  as  an  index  of  wave-length  and  regard 
saturation  as  an  indication  of  the  purity  or  homogeneity  of  the  radiant 
energy  forming  the  stimulus.  However,  careful  studies  show  that 
brilliance  depends  even  more  fundamentally  upon  wave-length  than 
upon  intensity,  the  so-called  visibility  curve  expressing  the  nature  of 
this  dependence  for  daylight  vision. 

It  appears,  moreover,  that  there  are  two  visibility  curves,  one  hold- 
ing for  day  vision  and  the  other  for  night  vision,  and  that  these 
curves  represent  the  responses  of  two  different  sets  of  retinal  receptors, 
the  cones  and  the  rods,  respectively.  The  facts  which  are  summarized 
in  the  so-called  duplicity  or  rod-cone  theory,  and  which  underlie  such 
phenomena  as  that  of  Purkinje,  must  be  accepted  by  any  hypothesis 
of  color  vision.  The  relations  between  brilliance  and  the  spectral 
constitution  of  the  stimulus  are  explicable  in  terms  of  the  two  visi- 
bility functions  and  the  simple  principle  of  the  additive  combination 
of  luminosities.  Fechner's  law,  with  its  upper  and  lower  deviations, 
provides  us  with  a  very  accurate  expression  of  the  manner  in  which 
brilliance,  regarded  as  a  psychologic  variable,  depends  upon  the 


The  Facts  and  Theories  of  Color  Vision  661 

intensity  of  the  stimulus,  this  law  representing  not  a  simple  linear,  but 
a  quasi-logarithmic  relationship. 

The  brilliance  of  a  color,  however,  depends  not  merely  upon  the 
three  fundamental  characteristics  of  the  stimulus,  but  upon  the  exact 
mode  of  incidence  of  the  stimulus  upon  the  retina,  including  also  the 
condition  of  the  retina  and  of  the  remainder  of  the  visual  mechanism 
at  the  given  moment.  Thus  the  brilliance  resulting  from  a  stimulus 
of  fixed  inherent  character  varies  with  its  position  in  the  retinal  field, 
with  its  form,  with  its  time  of  application  and  with  the  nature  of 
other  stimuli  which  are  simultaneously  active  in  outlying  portions 
of  the  retinal  area.  Many  of  these  relationships  have  been  worked 
out  quantitatively,  but  others  are  only  known  in  a  vague  way  and 
remain  to  be  investigated  in  the  future.  All  of  them  must  be  ex- 
plained by  a  completely  satisfactory  theory  of  color  vision. 

When  we  pass  from  the  consideration  of  brilliance  or  the  achromatic 
factor  in  vision  to  the  study  of  hue  and  saturation  we  encounter  an 
even  more  complex  system  of  relationships.  The  dependency  of  hue 
upon  the  wave-length  of  the  stimulus,  in  case  the  latter  is  mono- 
chromatic or  homogeneous,  has  been  very  definitely  determined,  but 
follows  a  mathematically  complex  law.  Although  hue  is  mainly  an 
index  of  wave-length  constitution,  it  is  also  a  function  of  intensity, 
since  at  very  high  intensities  all  stimuli  (of  whatever  constitution) 
tend  to  arouse  only  yellows  or  blues,  these  being  of  low  saturation  and 
passing  over  at  extremely  high  intensities  into  a  white.  The  depen- 
dency of  hue  as  well  as  of  saturation  upon  the  composition  of  stimulus 
mixtures  has  been  very  thoroughly  studied  and  the  results  are  repre-? 
sented  by  the  well-known  color-mixture  triangle.  The  fundamental 
fact  that  in  normal  vision  all  of  the  hues  can  be  reproduced  by  appro- 
priately proportioned  mixtures  of  three  simple  homogeneous  spectral 
stimuli  must  be  explained  by  any  color  theory  which  is  to  merit 
serious  consideration.  As  part  of  this  set  of  data  we  must  recognize 
the  importance  of  the  complementary  relationship  between  two  or 
more  stimuli,  by  virtue  of  which  they  combine  in  the  production  of  a 
white.  There  appear  to  be  an  indefinitely  large  number  of  pairs  of 
single  wave-lengths  in  the  physical  spectrum  which  are  capable  of 
combining  in  the  proper  intensity  ratios  to  yield  this  result,  but  it  is 
of  great  interest  that  in  the  mid-region  of  the  spectrum  there  is  a  range 
of  stimuli  which  have  no  single  complementaries  but  require  the 
addition  of  at  least  two  other  wave-lengths  to  yield  an  achromatic 
sensation. 


662          LEONARD  THOMPSON  TROLAND 

Although  saturation  is  ordinarily  regarded  as  an  index  of  the  purity 
or  homogeneity  of  the  stimulus,  careful  measurements  show  that  it 
varies  for  different  wave-lengths  even  when  they  are  unadulterated; 
the  mid-region  of  the  spectrum,  including  the  yellow  and  the  yellow 
green,  being  much  less  saturated  than  the  end  regions,  the  blue  and 
the  red.  As  we  have  already  seen,  saturation  also  depends  upon 
intensity,  being  reduced  for  all  stimuli  at  extremely  high  intensities 
and  for  certain  stimuli  which  act  upon  the  retinal  rods  at  very  low 
intensities.  Both  hue  and  saturation  depend,  like  brilliance,  upon  the 
mode  of  incidence  of  the  stimulus  upon  the  retina  and  upon  the  condi- 
tion of  the  latter.  The  dependency  of  the  hue  upon  the  position  of 
the  stimulus  in  the  retinal  field  is  summarized  in  our  doctrine  of  color 
zones  in  the  visual  field  which  is  of  much  importance  in  diagnostic 
technique.  Saturation  also  varies  in  a  parallel  manner.  The  phenom- 
ena of  color  contrast  are  well  known,  although  they  have  been 
studied  quantitatively  much  less  than  could  be  desired.  The  time 
of  action  of  a  stimulus,  with  the  correlated  effects  of  retinal  fatigue, 
influences  in  a  very  radical  manner  both  the  hue  and  the  saturation 
which  are  evoked. 

In  addition  to  dependencies  in  normal  persons,  illustrated  by  what 
we  have  just  said,  every  theory  of  color  vision  must  necessarily  con- 
sider the  astonishing  way  in  which  color  experiences  for  given  stimuli 
may  differ  in  different  individuals.  We  recognize  now  that  color 
blindness  is  only  a  radical  form  of  a  variability  which  is  always  to 
some  degree  manifest.  Not  only  do  hue  and  saturation  vary  for 
given  stimulus  conditions,  but  the  brilliance  which,  in  our  everyday 
attitudes,  we  regard  as  an  infallible  index  of  the  stimulus  intensity 
also  shows  radical  discrepancies  between  different  observers  as  indi- 
cated by  departures  of  their  visibility  curves  from  one  another. 

Clearly,  it  would  be  quite  impossible  for  me  to  enumerate  in  this 
brief  address  all  of  the  special  facts  of  color  vision.  My  purpose  is 
merely  to  suggest  to  you  as  vividly  as  I  can  the  extremely  involved 
relationships  which  are  resident  in  these  facts,  and  thus  to  show  you 
what  a  very  difficult  task  it  is  to  construct  a  really  satisfactory  hy- 
pothesis which  will  harmonize  at  once  with  these  special  facts  and 
with  the  more  general  requirements  laid  down  by  physiology  and 
by  psychophysics. 


The  Facts  and  Theories  of  Color  Vision  663 

IV.  THE  OLDER  THEORIES  OF  COLOR  VISION 
In  the  discussion  of  color  theories  all  ideas  appear  to  root  back 
ultimately  to  the  hypotheses  of  Young  and  of  Hering.  Both  of  these 
theories  postulate  the  existence  in  the  retinal  receptors,  or  somewhere 
in  the  afferent  section  of  the  response,  of  three  distinct  sensitive  sub- 
stances. However,  one  of  these  theories  is  a  physicist's  doctrine 
while  the  other  is  essentially  a  psychologist's  creation.  The  Young- 
Helmholtz  hypothesis  starts  with  the  stimulus  and  stops  before  it 
reaches  consciousness.  The  Hering  scheme,  on  the  other  hand, 
begins  with  an  introspective  analysis  but  becomes  vague  and  unsatis- 
factory by  the  time  it  has  been  carried  back  to  the  stimulus.  Physical 
thinkers  are  seemingly  satisfied  with  the  Young-Helmholtz  scheme 
because  they  are  sensation-blind.  Psychologists,  for  their  part, 
adhere  faithfully  to  the  Hering  conception  because  they  are  stimulus- 
blind.  Needless  to  say,  theories  which  rest  upon  a  defective  recogni- 
tion of  facts,  either  on  the  physical  or  the  physiologic  side,  can  scarcely 
lead  to  comprehensive  explanations. 

The  Ladd-Franklin  hypothesis  meets  this  situation  by  a  well-bal- 
anced consideration  of  both  the  psychologic  and  the  physical  facts  in 
the  case.  In  Mrs.  Franklin's  theory  the  three  substances  become  one 
substance  with  three  specific  reactivities.  The  resulting  scheme  not 
only  lays  due  emphasis  upon  the  facts  of  color-mixture  which  sub- 
stantiate the  Young-Helmholtz  hypothesis,  and  on  the  other  hand  upon 
the  psychologic  interrelations  of  the  colors  which  provide  the  basis 
for  the  Hering  theory,  but  fits  better  with  each  of  the  two  sets  of  facts 
than  did  the  original  doctrines.  Mrs.  Franklin  very  cleverly  crams 
two  imposing  arrays  of  facts  into  a  single  molecule,  and  thus  seems  to 
reduce  the  data  of  her  science  to  an  ideal  logical  explanation.  As  a 
pedagogic  device  nothing  better  than  this  could  be  desired,  but  it  may 
legitimately  be  questioned  whether  this  very  simplicity  of  the  Ladd- 
Franklin  hypothesis  does  not  constitute  the  principal  argument 
against  it,  if  we  are  seeking,  as  we  have  previously  avowed,  an  actual 
portrayal  of  the  missing  links  in  the  psychophysical  mechanism  of 
visual  response. 

We  have  seen  in  our  preliminary  analysis  of  the  general  structure  of 
visual  response  that  the  latter  mechanism  involves  a  plurality  of 
superposed  operations  upon  the  uppermost  of  which  only  does  color 
directly  depend.  All  three  of  the  best  known  color  theories,  those 
of  Young  and  Helmholtz,  of  Hering,  and  of  Ladd-Franklin,  are  con- 


664  LEONARD  THOMPSON  TROLAND 

cerned  primarily  with  the  mechanisms  of  a  single  stage  in  the  response, 
namely,  those  of  the  retinal  receptors.  Hering,  it  is  true,  endeavors 
to  expand  the  scope  of  his  theory  by  using  the  term  Netzhaut  to  desig- 
nate the  entire  response  mechanism  from  the  retina  to  the  brain,  but 
this  device  does  not  liberate  his  theory  from  the  difficulties  which 
go  with  the  simplicity  of  its  assumptions.  When  we  look  at  the 
problem  in  a  realistic  attitude  we  see  that  a  theory  which  deals  with 
only  a  single  stage  in  the  response  has  very  little  chance  of  explaining 
all  of  the  facts  of  color  vision,  and  moreover  is  not  consistent  with  the 
general  demands  of  the  case. 

Although  by  far  the  greater  number  of  the  extant  theories  of  color 
vision  have  dealt  exclusively  with  the  retinal  process  there  have  been 
in  the  past  an  appreciable  number  of  attempts  to  subdivide  the  visual 
apparatus,  and  to  hypothecate  different  mechanisms  for  the  several 
stages.  Theories  of  this  type  are  known  as  zone  theories  because  they 
break  up  the  visual  mechanism  into  separate  zones.  In  the  most 
primitive  doctrines  of  this  sort  only  two  zones  are  considered,  those 
corresponding  with  the  retinal  and  the  cerebro-cortical  activities, 
respectively.  A  plausible  suggestion  for  such  a  two-zone  doctrine 
would  obviously  be  to  assign  the  mechanism  of  the  Hering  theory 
exclusively  to  the  cortex  and  to  reserve  the  Young-Helmholtz  appara- 
tus for  the  retina,  since,  as  we  have  seen,  Hering  starts  with  conscious- 
ness (which  is  directly  correlated  with  the  central  stage)  whereas  the 
Young-Helmholtz  scheme  has  been  developed  mainly  with  reference 
to  stimuli.  A  view  of  this  general  character  has  been  advocated  by 
von  Kries. 

Hering,  it  will  be  remembered,  divides  the  psychologically  primary 
colors  into  three  pairs  of  antagonists :  black  versus  white,  red  versus 
green,  and  yellow  versus  blue.  These  antagonistic  pairs  he  associates 
psychophysically  with  similarly  antagonistic  processes  of  catabolism 
and  anabolism  in  his  three  visual  substances,  respectively.  He  ex- 
plains a  large  number  of  special  visual  phenomena  by  means  of  these 
antagonistic  interactions  of  the  specified  color  mechanisms.  The  rela- 
tionships of  complementaries,  for  example,  are  said  to  depend  upon 
the  balanced  excitation  of  such  mutually  neutralizing  processes,  as 
do  also  the  processes  of  simultaneous  and  successive  contrast.  If  we 
take  the  cue  from  von  Kries  and  place  Hering's  three  substances, 
or  their  neurologic  equivalents  in  the  brain,  we  shall  naturally  look 
for  the.  explanation  of  these  special  particular  facts  in  the  central  zone 
of  visual  response.  It  seems  more  probable  that  antagonistic  rela- 


The  Facts  and  Theories  of  Color  Vision  665 

tionships  of  this  sort  should  exist  in  the  nerve  centers  than  that  they 
should  be  found  in  the  receptors,  since  the  latter  are  essentially 
excitatory  in  their  responses  whereas  in  the  centers  we  as  often  find 
inhibition  as  excitation.  In  other  departments  of  sensation,  for 
example  in  temperature  sensibility,  the  facts  demonstrate  immedi- 
ately the  central  locus  of  the  antagonistic  interactions  between  simul- 
taneously operative  processes.  On  the  other  hand,  the  three  sub- 
stances of  the  Young-Helmholtz  theory  seem  ideally  fitted  to  operate 
within  the  receptor  cells  of  the  retina,  since  their  reactions  are  con- 
ceived wholly  in  terms  of  excitation  and  may  easily  be  regarded  as 
instances  of  a  purely  physical  process  of  molecular  resonance. 

Although  this  dual  zone  hypothesis  excludes  any  specific  con- 
sideration of  the  conduction  mechanism  which  links  the  retina  with 
the  cortex  it  nevertheless  necessitates  a  set  of  intermediate  assump- 
tions which  state  exactly  how  the  Young-Helmholtz  apparatus  in 
the  retina  is  linked  up  with  the  Hering  mechanism  in  the  brain. 
Naturally,  we  like  to  conceive  of  such  relations  as  being  of  the  simplest 
possible  point  to  point  character,  but  there  seems  to  be  no  a  priori 
reason  why  we  should  insist  upon  such  forms  of  connection.  If 
instead  of  supposing  that  the  red  sensitive  substance  in  the  retina  is 
linked  exclusively  with  the  red  producing  elements  of  the  cortex  we 
associate  the  former  with  the  yellow  and  white  generating  brain 
mechanisms,  as  well  as  with  the  red,  we  shall  obtain  a  system  which 
has  a  considerably  enhanced  capacity  for  dealing  with  the  special 
facts  of  color  vision.  We  shall  be  able  to  explain,  for  example,  why 
it  is  that  a  pure  spectral  red  stimulus  degenerates  into  an  almost 
perfect  yellow  as  a  result  of  continued  fixation,  or  adaptation,  and 
we  shall  be  able  to  account  for  the  differences  in  luminosity  curves 
which  exist  between  the  two  common  forms  of  partial  color  blindness. 
Thus  a  combination  of  the  Young-Helmholtz  and  Hering  systems 
into  a  two  zone  hypothesis  with  a  well-considered  set  of  linkages 
between  the  two  mechanisms  should  provide  us  with  a  theory  having 
a  very  respectable  explanatory  power. 

Von  Kries  is  by  no  means  the  only  one  among  the  earlier  writers 
on  color  vision  to  suggest  a  zonal  treatment  of  the  visual  mechanisms. 
The  very  interesting  but  little  known  theory  of  Bonders  is  explicitly 
of  the  zonal  type.  Bonders  agrees  that  the  retinal  mechanism  is  as 
described  by  Young  and  Helmholtz,  but  he  supposes  that  in  the  brain 
quite  a  different  apparatus  is  functioning.  This  cerebral  system 
consists  of  a  single  chemical  substance  which  is  capable  of  being  split 


666  LEONARD  THOMPSON  TROLAND 

along  four  different  diametrical  lines  of  cleavage,  corresponding  with 
the  four  psychologically  primary  hues,  red,  yellow,  green  and  blue. 
Simultaneous  cleavage  along  all  possible  lines  yields  the  sensation  of 
white  or  gray,  while  various  mixed  modes  of  cleavage  result  in  colors 
of  intermediate  hues  or  saturation.  The  theory  of  Schenck,  with 
its  distinction  between  stimulus-receptors  and  sensation-stimulators, 
is  also  at  least  implicitly  a  zone  doctrine.  G.  E.  Miiller's  edition 
of  the  Hering  theory  is  an  attempt  to  put  the  latter  scheme  into  zonal 
form  with  a  minimum  of  logical  change,  while  McDougall's  discussion 
of  the  Young-Helmholtz  theory  performs  a  similar  service  for  the 
latter  hypothesis.  All  of  these  views  are  subject  to.  the  objection 
that  they  are  more  complex,  involving  more  logically  independent 
assumptions  than  their  parent  single  zone  hypotheses.  However, 
the  failure  of  the  latter  to  satisfy  all  of  the  facts  in  the  case  indicates 
that  an  increased  complexity  of  assumptions  is  essential  in  order  to 
provide  us  with  a  really  satisfactory  conception  of  the  mechanisms 
which  are  actually  involved. 

V.  SOME  NEWER  THEORIES  OF  COLOR  VISION 
When  we  see  clearly  how  manifold  are  the  factors  which  our  general 
knowledge  of  the  visual  mechanism  inevitably  imposes  upon  our 
consideration,  we  must  realize  definitely  how  futile  must  be  the  search 
for  a  simple  but  all  comprehensive  explanation  of  visual  phenomena. 
In  the  domain  of  physics  it  has  often  proved  possible  to  explain  a 
highly  complex  array  of  facts  by  means  of  a  single  simple  assumption. 
General  considerations,  however,  make  it  highly  probable  that  this 
possibility  is  limited  to  the  inorganic  realm.  While  we  are  committed 
to  the  view  that  organic  or  vital  activities  are  essentially  reducible 
to  the  concepts  of  physics  or  chemistry  this  very  fact  makes  it  inevit- 
able that  living  organisms  should  possess  a  most  elaborate  physical 
structure.  Vitality  is  in  essence  nothing  but  intricacy  and  instability, 
and  we  should  not  be  surprised  if  in  biology  true  explanations  should 
sometimes  turn  out  to  be  more  complicated  than  are  the  apparent 
facts. 

If  we  pursue  this  line  of  thought,  we  shall  not  only  permit  our  visual 
theorists  to  distinguish  definitely  between  the  mechanisms  which  are 
operative  in  the  retina  and  those  which  function  in  the  brain  but  we 
shall  sanction  an  even  more  detailed  analysis  of  the  hypothetical 
mechanisms  into  zones  or  stages  of  the  response.  On  general  grounds 
there  appears  to  be  no  reason  for  supposing  that  the  conduction 


The  Facts  and  Theories  of  Color  Vision  667 

processes  transpiring  in  the  optic  nerve  fibers  are  identical,  or  cor- 
related point  to  point,  with  either  the  retinal  excitations  or  the  cere- 
bral processes.  Accordingly  we  might  take  the  further  step  of  intro- 
ducing a  conductional  or  intermediate  zone  in  our  theories,  lying 
between  the  retina  and  the  brain.  This  step  has  actually  been  taken 
in  a  recent  very  promising  hypothesis  which  is  due  to  the  Norwegian 
psychologist,  Harald  K.  Schjelderup,  whose  views  are  worthy  of  a 
somewhat  detailed  presentation. 

Schjelderup  accepts  the  classification  of  colors  made  by  Hering 
into  six  primaries,  red,  yellow,  green  and  blue,  black  and  white,  and 
complies  with  the  usual  psychophysical  principle  in  correlating  these 
unit  for  unit  with  six  corresponding  physiologic  elements  in  the  brain. 
These  six  components  in  the  central  zone  or  stage,  however,  are  con- 
ceived to  be  independently  functional  mechanisms,  not  associated  to- 
gether into  antagonistic  pairs,  as  in  Bering's  formula,  so  that  it  is 
possible — as  in  certain  cases  of  color-blindness — for  any  one  of  the 
cerebral  components  to  drop  out  without  involving  others.  The 
admitted  antagonism  between  certain  of  the  colors  is  laid  to  the  dis- 
tinctive mechanism  of  another  and  more  peripheral  stage  in  the  re- 
sponse mechanism  which  Schjelderup  calls  the  Zwischenprozesse  or  "  be- 
tween-process,"  and  which  we  may  conceive  to  represent  the  nerve 
conduction  between  the  retina  and  the  brain.  In  this  zone,  Schjel- 
derup hypothecates  the  existence  of  paired  processes  corresponding 
exactly  with  the  Hering  scheme,  so  that  any  dropping  out  of 
factors  here  will  involve  at  the  least  two  unitary  colors.  The  indi- 
vidual single  color  processes  of  this  intermediate  zone  are  conceived 
to  be  connected  in  a  simple  point  to  point  manner  with  the  cor- 
responding individual  processes  of  the  central  zone. 

Tracing  the  process  backward  to  the  retina,  Schjelderup  assumes 
the  existence  in  the  receptor  zone,  of  three  photochemic  substances 
possessing  reactivities  to  light  similar  in  a  general  way  to  those  of  the 
Hering  hypothesis.  One  of  these  substances  responds  by  undergoing 
oxidation  to  practically  all  of  the  visible  wave-lengths  of  the  spectrum. 
The  other  two  substances,  however,  are  oxidized  by  the  longer  waves 
but  are  reduced  chemically  by  the  shorter  ones,  the  maxima  of  re- 
sponse either  by  oxidation  or  reduction  for  the  two  substances  lying 
at  different  points  in  the  spectrum,  so  that  one  reacts  mainly  to 
physical  red  and  green  whereas  the  other  responds  principally  to 
the  physical  yellow  and  blue.  The  linkage  between  these  retinal 
activities  and  those  of  the  conduction  zone  is  not,  like  that  between 


668  LEONARD  THOMPSON  TROLAND 

the  latter  and  the  cortical  process,  a  simple  point  to  point  corres- 
pondence— except  in  the  case  of  the  substance  which  responds  to  all 
of  the  wave-lengths  of  the  spectrum.  This  latter  substance  is  linked 
solely  with  the  intermediate  process,  which  is  associated  indirectly 
with  the  sensation  of  white.  The  long-wave  oxidation  process, 
however,  is  linked  not  only  with  the  red  sensation  processes  of  higher 
zones,  but  also  with  those  of  white  and  yellow,  while  the  corresponding 
reduction  reaction  is  associated  not  merely  with  the  green  sensation 
but  likewise  with  blue  and  black.  The  mid-spectral  oxidation 
process,  in  turn,  is  connected  with  both  green  and  yellow  sensation 
processes,  while  the  corresponding  reduction  activity  evokes,  through 
the  intermediate  mechanism,  both  red  and  blue.  Although  this  system 
seems  intricate,  it  is  by  no  means  difficult  to  apply  to  the  facts  and 
it  is  probably  no  more  complex  than  they  actually  demand. 
Schjelderup  demonstrates  that  the  eight  best  known  forms  of  color 
blindness  can  all  be  explained  in  terms  of  his  hypothesis  as  conse- 
quences of  the  dropping  out  of  one  or  more  of  the  component  activities 
in  his  three  zone  mechanism. 

If  time  permitted  I  would  review  for  you  certain  other  of  the  more 
modern  theories  of  color  vision.  I  would  outline  for  you  the  recent 
elaborate  speculations  of  John  Joly,  in  which  the  modern  quantum 
conception  of  radiation  is  brought  to  bear  upon  the  theory  of  retinal 
reaction.  I  might  also  summarize  the  very  suggestive  speculations 
of  R.  A.  Houstoun,  which  take  the  form  of  a  zone  theory.  I  might 
refer  to  the  ideas  of  Barton  and  Browning,  as  well  as  to  those  of  H.  E. 
Ives,  bearing  upon  the  physics  of  retinal  response.  I  might  tell  you 
something  of  Hecht's  very  suggestive  researches  regarding  the 
chemistry  of  visual  reactions.  I  might  even  refer  to  the  fantastic 
imaginings  of  Edridge-Green.  I  must  content  myself,  however,  with 
the  foregoing  general  comments,  which  I  hope  will  not  leave  you 
altogether  without  some  inkling  as  to  what  good  a  color  theory  may 
be,  and  how  good  some  of  the  current  theories  probably  are. 


THE  PRODUCTION  AND  TRANSMISSION  OF 
CERTAIN  EYE  DEFECTS1 

PROF.  M.  F.  GUYER 

University  of  Wisconsin 

By  way  of  introduction  to  the  discussion  of  eye  defects,  I  wish  to 
review  briefly  some  points  in  the  embryologic  development  of  the 
eye.  Although  it  will  prove  to  be  an  old  story  to  ophthalmologists, 
I  feel,  nevertheless,  that  by  so  doing  I  can  get  before  you  most  effec- 
tively the  materials  I  have  to  present. 

Cleavage  of  the  fertilized  ovum,  formation  of  the  three  fundamental 
germinal  layers,  and  general  embryogeny  in  the  rabbit  do  not  differ  in 
any  important  ways  from  these  same  processes  in  other  mammalian 
forms.  Through  the  successive  divisions  which  begin  shortly  after 
penetration  of  the  ovum  by  the  spermatozoon,  a  mulberry-like  mass 
of  cells  enclosed  by  the  zona  radiata  is  built  up.  Some  of  the  cells  divide 
more  rapidly  than  others,  so  that  the  resulting  spherical  mass  comes  to 
consist  of  a  central  group  of  larger,  more  granular  cells  surrounded  by 
a  superficial  layer  of  smaller,  clearer  elements.  Soon  fluid  appears 
between  the  central  cells  and  the  peripheral  layer  except  at  one  side. 
As  the  liquid  accumulates  the  entire  mass  becomes  transformed  into 
a  fluid-filled  vesicle  consisting  of  a  single  layer  of  small  transparent 
cells  with  the  original  central  mass  projecting  from  one  side  into  the 
cavity.  The  outer  layer,  termed  the  trophoblast,  is  concerned  only 
with  the  establishment  of  relations  between  the  developing  organism 
and  the  uterine  mucosa.  The  inner  mass  is  the  part  out  of  which  the 
embryo  is  formed.  At  this  stage  the  developing  ovum  is  commonly 
termed  the  blastodermic  vesicle  or  blastocyst. 

Seen  from  without,  the  germinal  area  appears  as  a  circular  disc  at 
the  upper  pole  of  the  blastocyst.  Within  this  disc  the  cells  are 
rapidly  shaping  up  into  the  two  primitive  germinal  layers — ectoderm 
and  entoderm.  By  unequal  growth  the  disc  soon  becomes  oval,  then 
more  or  less  pear-shaped.  At  its  smaller  end  a  median  denser  streak, 
formed  by  a  keel-like  thickening  of  the  ectoderm,  appears.  This  is 

1  Illustrated  by  lantern-slides  and  living  animals. 
669 


670  M.  F.  GUYER 

the  so-called  primitive  streak.  From  each  side  of  the  primitive  streak 
cells  are  budded  off  between  ectoderm  and  entoderm  to  form  the 
third  germinal  layer,  the  mesoderm.  The  mesoderm  grows  rapidly 
until  it  finally  spreads  around  the  entire  wall  of  the  blastocyst  on  the 
inside.  Only  that  part  confined  to  the  germinal  area,  however,  takes 
part  in  the  formation  of  the  embryo.  Ultimately  the  mesoderm 
splits  into  two  layers,  one  of  which  adheres  to  the  ectoderm  and, 
within  the  germinal  disc,  helps  to  form  the  body  wall;  the  other 
adheres  to  the  entoderm,  and  together,  inside  the  embryo,  they  form 
the  alimentary  tract  and  its  outgrowths. 

As  the  embryo  takes  form,  a  shallow  median  groove,  the  neural 
groove,  appears  on  its  surface  in  front  of  the  primitive  streak.  This 
is  the  first  indication  of  the  central  nervous  system.  The  groove  is 
formed  by  the  upgrowth  of  ectodermal  folds,  the  neural  folds;  by  con- 
tinuation of  the  upgrowth  it  is  converted  into  a  deep  furrow.  Ulti- 
mately the  neural  folds  fuse  above  in  the  mid-axial  line  and  thus  form 
a  closed  canal,  the  neural  canal,  which  is  the  forerunner  of  the  cerebro- 
spinal  nervous  system.  The  surface  ectoderm  soon  overgrows  the 
neural  tube  and  becomes  separated  from  it.  The  anterior  end  of  the 
neural  canal  enlarges  further  to  form  the  three  primary  brain-vesicles, 
the  fore-brain,  mid-brain,  and  hind-brain. 

Since  it  is  from  the  fore-brain  that  the  eyes  originate,  we  shall  con- 
fine our  attention  to  this  region  only.  It  should  be  understood  at  the 
outset  that  there  is  a  sharp  distinction  embryologically  between  the 
sensory  part  of  the  eye  and  the  accessory  parts.  The  sensory  part 
of  any  sense-organ  is  always  the  first  to  arise  in  the  embryo.  The 
beginnings  of  the  optic  vesicles  appear  very  early  as  lateral  expansions 
of  the  fore-brain,  even  before  the  latter  is  closed  dorsally.  They  are 
well  established  in  the  rabbit  embryo  by  the  ninth  day.  The  cavities 
of  the  optic  vesicles  are  widely  confluent  at  first  with  the  main  cavity 
of  the  fore-brain,  but  as  development  proceeds  this  broad  communica- 
tion is  rapidly  reduced  by  the  downward  growth  of  a  ridge  of  tissue 
which  soon  distinctly  marks  off  the  optic  vesicles  from  the  fore-brain 
proper  by  narrowing  the  original  communication  to  a  tubular  stalk, 
the  optic  stalk.  Through  this  stalk,  which  is  attached  to  the  ventral 
portion  of  the  fore-brain,  the  cavity  of  the  latter  is  still  continuous 
with  the  cavities  of  the  optic  vesicles. 

The  optic  vesicles  extend  laterally  until  they  come  in  contact  with 
the  primitive  epidermis  or,  at  least,  until  separated  from  it  by  only  a 
thin  layer  of  connective  tissue.  Each  optic  vesicle  then  becomes 


The  Production  and  Transmission  of  Certain  Eye  Defects      671 

converted  into  a  two-walled  optic  cup  by  a  process  of  invagination 
which  occurs  at  two  places,  the  outer  and  the  ventral  surfaces.  With 
the  first,  the  formation  of  the  crystalline  lens  is  associated ;  the  second 
constitutes  the  so-called  choroidal  fissure.  The  inner  wall  of  the  optic 
cup,  destined  to  become  the  sensory  part  of  the  retina,  is  much  thicker 
than  the  outer  wall,  which  will  eventually  become  the  pigment  layer 
of  the  retina.  These  infoldings  of  the  walls  of  the  optic  vesicles  to 
form  the  optic  cups  commence  on  the  tenth  day  in  the  rabbit  and  are 
completed  by  the  fourteenth  day.  The  crystalline  lens  is  making  its 
appearance  simultaneously  with  these  changes. 

In  the  formation  of  the  choroidal  fissure  the  infolding  extends  a 
certain  distance  along  the  optic  stalk  toward  the  brain,  so  that,  near 
the  eye,  the  optic  stalk  is  a  tube  deeply  grooved  along  the  under  sur- 
face by  an  infolding  of  its  thick  lower  wall.  It  is  along  this  groove, 
through  the  choroidal  fissure,  that  the  central  artery  of  the  retina 
gains  admittance  to  the  eye.  This  artery  supplies  the  retina  through- 
out life,  but  during  the  development  of  the  eye  it  also  supplies  the 
vitreous  body  and  the  capsule  of  the  growing  lens.  At  first  rather 
wide,  the  choroid  fissure  becomes  more  and  more  narrow  until  under 
normal  conditions  it  closes  altogether  soon  after  the  entrance  of  the 
arterial  blood-vessel,  but,  as  you  well  know,  this  fissure  may  remain 
unclosed,  producing  the  not  uncommon  malformation  known  as 
coloboma.  I  stress  this  condition,  at  this  point,  because  of  its  bearing 
upon  some  of  the  eye-anomalies  I  shall  describe  later. 

The  lens  first  appears  before  the  invagination  of  the  primary  optic 
vesicle,  at  the  place  where  the  epidermis  passes  over  the  surface  of  the 
latter.  At  first  a  slightly  thickened  disc,  it  soon  invaginates  to  form 
a  small  pit,  which  by  approximation  of  the  edges  becomes  converted 
into  the  lens-vesicle.  In  the  cavity  of  the  lens  of  the  rabbit  and  of  man 
epithelial  cells  occur;  but  their  significance  is  unknown.  They  ulti- 
mately degenerate  and  disappear.  The  lens-vesicle  finally  becomes 
constricted  off  from  the  surface-epidermis. 

As  the  optic  cup  invaginates  it  and  the  lens  draw  apart  somewhat 
although  they  remain  connected  by  protoplasmic  strands.  The  inner 
wall  of  the  lens- vesicle  very  early  increases  in  thickness  and  encroaches 
on  the  lens-cavity  but  the  outer  wall  remains  thin. 

This  thin  anterior  layer  persists  throughout  life  as  a  simple  layer 
of  cubical  cells,  the  so-called  lens-epithelium;  but  the  cells  of  the  pos- 
terior layer  grow  forward  into  the  cavity  as  the  lens-fibers.  The 
central  fibers  are  straight  and  long;  the  peripheral  fibers,  somewhat 


672  M.  F.  GUYER 

curved,  become  shorter  and  shorter  toward  the  surface  of  the  lens, 
where  they  merge  into  columnar  cells  which  are  continuous  with  the 
anterior  lens-epithelium.  The  cavity  is  gradually  obliterated  and 
the  developing  lens  thus  becomes  a  solid  body.  The  part  formed  so 
far,  however,  constitutes  only  the  core  of  the  adult  lens.  Around  this 
core  (beneath  the  lens  epithelium  of  the  front  surface  of  the  organ) 
successive  coats  of  lens-fibers  arise,  lying  in  layers  one  over  another 
like  the  coats  of  an  onion.  These  secondary  fibers  arise  at  the  equator 
of  the  lens,  and,  increasing  rapidly  in  length,  spread  over  the  ends  of 
the  first-formed  fibers. 

In  discussing  the  formation  of  the  optic  cup  it  has  already  been 
pointed  out  that  the  deeper  parts  of  this  structure  become  the  retina. 
There  is  a  thinner  outer  rim,  however,  marked  off  from  the  retinal 
region  by  the  so-called  or  a  serrata.  This  thinner  portion,  together 
with  invading  mesenchymatous  tissue,  is  concerned  in  the  formation 
of  the  iris  and  the  ciliary  body. 

The  cornea  and  its  associated  structures  are  formed  mainly  by  a 
layer  of  invading  mesenchymatous  tissue  which  surrounds  the  lens 
and  separates  it  by  a  thin  sheet  from  the  epidermis.  This  sheet 
thickens  by  immigration  of  adjacent  cells;  then  it  separates  into  two 
layers,  one  of  which,  the  pupillary  membrane,  remains  thin  and  becomes 
very  vascular,  while  the  other  becomes  the  early  cornea;  covered, 
however,  by  a  corneal  epithelium  of  ectodermal  origin.  Between  the 
two  layers  the  anterior  chamber  of  the  eye  appears  as  a  narrow  fissure 
which  becomes  filled  with  fluid,  the  aqueous  humor,  and  gradually 
increases  in  size  with  the  appearance  of  the  iris.  In  mammals,  the 
pupil  is  closed  at  first  by  a  thin  vascular  connective-tissue  membrane 
(pupillary  membrane)  which  also  forms  the  anterior  part  of  the  tunica 
vasculosa  lentis.  The  blood-vessels  of  this  anterior  part  are  continu- 
ous with  those  of  the  connective  tissue  at  the  margins  of  the  optic 
cup.  It  will  be  noted  from  this  that  during  its  main  period  of  develop- 
ment the  lens  of  the  fetal  rabbit  is  surrounded  by  a  membrane,  the 
posterior  part  of  which  is  supplied  by  the  hyaloid  artery,  the  anterior 
surface,  by  branches  of  the  anterior  ciliary  arteries.  Thus,  by  the 
thirteenth  day,  the  lens  is  relatively  large  and  is  inclosed  in  a  mem- 
brane richly  supplied  with  blood-vessels.  Before  birth  the  blood- 
vessels of  this  membrane  disappear  and  the  membrane  becomes  (or 
merges  with?)  the  lens-capsule. 

During  its  earlier  formation  the  cavity  of  the  optic  cup  is  practically 
filled  with  the  newly  forming  lens,  but  as  development  proceeds  the 


The  Production  and  Transmission  of  Certain  Eye  Defects      673 

retinal  layer  of  the  cup  draws  away  from  the  lens  and  thus  forms  the 
vitreous  chamber.  However,  nuclear-free  protoplasmic  threads  still 
connect  the  lens  and  the  future  retinal  epithelium,  and  it  is  this  net- 
work which  apparently  constitutes  the  formed  elements  of  the  vitreous 
body  and  the  zonule  of  Zinn.  There  is  also  some  invasion  by  mesen- 
chymatous  tissue.  The  vitreous  matrix  rapidly  increases  in  amount 
and  becomes  more  and  more  watery.  Later  it  is  surrounded  by  a 
structureless  membrane,  the  membrana  hyaloidea.  As  noted  earlier, 
the  hyaloid  artery,  a  branch  of  the  retinal  artery,  extends  across  the 
vitreous  chamber  from  the  entrance  of  the  optic  stalk  and  not  only 
supplies  the  tunica  vasculosa  of  the  lens  but  gives  off  branches  to  the 
vitreous  body  itself.  Along  with  the  hyaloid  artery  these  disappear 
before  birth,  leaving  the  vitreous  body  of  the  adult  destitute  of  blood- 
vessels. The  old  path  of  the  hyaloid  artery  persists,  however,  as  a 
canal  filled  with  fluid,  the  canalis  hyaloideus,  or  canal  of  Stilling. 

The  optic  nerves  arise  in  connection  with  the  original  optic  stalks. 
The  interior  of  each  stalk  becomes  converted  into  a  glial  network 
through  which  nerve-fibers  having  their  origin  from  ganglion  cells  in 
the  retina  grow  inward  to  the  brain. 

The  sclerotic  and  choroid  coats  respectively  arise  as  two  layers 
differentiated  from  the  mass  of  mesenchyme  which  surrounds  the 
optic  cup.  In  front,  the  cornea  is  continuous  with  the  sclerotic.  The 
two  are  at  first  identical  in  structure ;  it  is  only  later  that  the  cornea 
becomes  transparent.  In  the  rabbit  the  sclerotic  coat  becomes 
glistening  white.  It  contains  no  cartilage. 

As  we  have  seen,  the  retinal  part  of  the  eye  has  a  very  different 
origin  embryologically  from  the  outer  and  middle  coats.  It  never 
becomes  closely  fused  with  them  and  may  thus  easily  be  detached. 
This  is  a  condition  which  has  direct  bearing  upon  certain  of  the  eye- 
anomalies  we  have  found,  characterized  by  detachment  of  the  retina. 

A  number  of  interesting  facts  about  the  developmental  mechanics 
of  the  eye  have  come  to  light  through  the  efforts  of  experimental 
embryologists.  It  will  not  be  time  misspent,  therefore,  if  we  digress 
a  bit  to  review  some  of  the  more  significant  of  these,  which  have  bear- 
ings on  our  problems  of  eye-anomalies.  For  example,  there  has  been 
much  discussion  regarding  the  way  in  which  cyclopean  defects  occur. 
The  condition,  as  you  recall,  ranges  all  the  way  from  an  aborted  or  a 
full-sized  single,  median  eye,  through  eyes  showing  varying  degrees 
of  doubleness  to  two  separate  eyes  that  are  merely  unusually  close 
together.  While  cyclopia  has  long  been  known  to  medical  men  as  a 
43 


674  M.  F.  GUYER 

rather  rare  teratological  phenomenon,  experimental  embryologists, 
and  notably  among  them  Stockard  (1909),  have  developed  chemical 
means  by  which,  in  certain  species  of  fish,  at  least,  cyclopia  can  be 
induced  almost  at  will.  Stockard  has  found  that  when  the  developing 
eggs  of  Fundulus  heteroclitus,  for  instance,  are  subjected  to  the  action 
of  various  magnesium  salts  dissolved  in  sea  water,  a  large  percentage 
of  them — as  many  as  sixty  in  one  hundred  individuals — develop  a 
single  median  eye  instead  of  the  ordinary  pair.  He  and  others  have 
also  secured  cyclopean  monsters  through  the  use  of  alcohol,  ether,  and 
certain  other  reagents. 

Stockard  believes  such  results  are  due  to  an  early  developmental 
arrest,  and  he  raises  the  question  as  to  the  original  location  of  the 
optical  elements  in  the  embryonal  central  nervous  system.  Visibly, 
the  eye-antecedents  first  appear  as  paired  outgrowths  from  the  primary 
fore-brain,  but  what  is  their  earlier  condition  in  the  medullary  tissues? 
Stockard  (1913),  partly  as  an  inference  from  the  way  his  cyclopean 
monsters  are  formed,  but  also  from  the  outcome  of  certain  operations 
he  performed  on  embryos  of  one  of  the  salamanders  (Amblystoma 
punctatum),  has  come  to  the  conclusion  that  the  original  material  of 
the  optic  outgrowths  is  median  and  single,  and  that  later  it  separates 
into  two  growth-regions  which,  developing  in  lateral  directions,  give 
rise  to  the  primitive  optic  vesicles.  He  regards  cyclopia  as  due  to  an 
arrest  in  eye-formation  while  the  optic-elements  are  still  in  the  median 
axis  of  the  developing  nervous  system.  This  is  contrary  to  the  older 
view  which  located  the  antecedents  of  the  eyes  in  lateral  positions 
along  the  margins  of  the  medullary  plate,  and  held  that  the  cyclopean 
defect  was  due  to  a  coming-together  and  fusion  of  the  incipient  optic 
vesicles  in  the  median  plane. 

Stockard  submitted  the  problem  to  experimental  test  by  excising 
various  parts  of  the  medullary  plate.  He  found  that  in  the  very 
young  embryo,  operations  which  removed  the  tissue  of  the  median 
line  prevented  the  development  of  eyes,  while  operations  in  which  the 
removed  tissue  was  confined  to  a  lateral  position  though  still  involving 
the  lateral  fold,  in  nine  of  the  eleven  embryos  employed,  did  not  pre- 
vent the  development  of  a  perfect  eye  on  the  operated  side  as  well  as 
on  the  other  side.  His  inference  is,  of  course,  that  the  material  for 
both  eyes  was  medially  located  at  the  time  of  operation.  Lateral 
operations  upon  somewhat  older  embryos  indicated  that  the  eye- 
antecedents,  in  these  later  stages,  were  coming  to  occupy  more  lateral 
regions.  Apparently  the  different  degrees  and  kinds  of  cyclopean 


The  Production  and  Transmission  of  Certain  Eye  Defects      675 

defect  depend  in  large  measure  upon  the  stage  in  development  at 
which  the  arrest  occurs.  If  cyclopia  is  complete,  according  to  Stock- 
ard's theory,  obviously  the  arrest  must  come  before  the  median  tissue 
has  separated  into  two  lateral  components.  Stockard's  comparative 
study  of  cyclopean  individuals  in  which  the  single  eye  grades  all  the 
way  down  from  an  eye  of  normal  size  to  one  of  extremely  minute 
dimensions  confirms  him  in  the  belief  that  the  earliest  eye  material 
occupies  a  median  position.  Differences  of  size  are  due  to  different 
degrees  of  completeness  of  the  arrest.  The  "hour-glass"  eye,  or  incom- 
plete cyclopia,  he  regards  as  due  to  a  later  or  a  less  complete  arrest. 
To  secure  cyclopia  in  Fundulus  the  embryo  must  be  subjected  to 
appropriate  stimuli  not  later  than  the  fifteen-hour  stage  of  develop- 
ment. Since  the  optic  vesicles  do  not  appear  under  normal  conditions 
until  about  thirty  hours  of  development,  it  is  apparent  that  important 
steps  in  their  formation  are  in  progress  long  before  the  two  vesicles 
themselves  become  visible. 

Under  the  same  experimental  condition  which  causes  cyclopia  an 
entirely  different  type  of  eye-anomaly  is  common,  in  which  one  normal 
eye  occurs  in  the  usual  lateral  position  while  the  eye  of  the  opposite 
side  may  be  wholly  lacking  or  may  show  various  degrees  of  imperfec- 
tion. Such  an  anomaly  is  termed  monophthalmia  asymmetrica,  to 
distinguish  it  from  the  cyclopean  type.  Stockard  is  inclined  to  believe 
that  in  such  cases  some  inhibitive  influence  becomes  operative  on  the 
one  center  of  growth  after  the  future  eye  centers  have  begun  to  be 
localized  in  more  or  less  lateral  positions.  He  found  some  notable 
examples  of  this  in  chick  embryos  from  eggs  which  had  been  exposed 
to  alcohol  fumes,  as  well  as  among  his  fish  embryos.  Under  such 
methods  of  treatment  not  infrequently,  also,  both  eyes  would  remain 
small  and  defective.  Inasmuch  as  the  same  types  of  defect  may  be 
produced  by  any  one  of  a  number  of  different  chemical  or  physical 
means,  it  is  clear  that  the  response  in  such  cases  is  not  specific  with 
respect  to  a  given  agent.  The  widely  differing  agents  apparently 
merely  act  similarly  on  the  embryonic  organism  or  on  certain  of  its 
parts  at  critical  stages  in  their  development.  Stockard's  explanation 
of  such  defects  as  developmental  arrests  of  particular  structures  at 
such  critical  periods  is  the  most  acceptable  that  has  been  offered. 

Child  (1915,  1921)  has  shown  in  numerous  studies  extending  over  a 
period  of  twenty  years  or  more,  on  a  wide  range  of  animals,  that  the 
developing  embryo  of  bilaterally  symmetric  forms  has  a  marked 
polarity  along  an  antero-posterior  axis,  with  different  rates  of  metab- 


676  M.  F.  GUYER 

olism  at  different  points  along  the  axis.  In  the  early  embryo  the 
developing  head-end  always  shows  the  highest  rate  of  activity,  the 
activity  gradually  diminishing  toward  the  posterior  end.  Child  has 
also  shown  that  the  more  active  a  region  is,  the  more  susceptible  it  is 
to  adverse  chemical  or  physical  influences.  Since  the  rate  of  oxida- 
tion gradually  diminishes  along  the  gradient  from  the  region  of  highest 
activity,  he  holds  that  differences  in  oxygen  supply  probably  play  a 
very  important  part  in  the  local  metabolic  differences. 

In  a  recent  experimental  study  on  twins,  double  monsters  and  other 
deformities,  and  on  interactions  among  embryonic  organs,  Stockard 
(1921)  likewise  attributes  much  importance  to  reduction  of  oxygen 
supply  at  critical  stages  of  embryonal  or  organal  development  in 
causing  arrests  which  result  in  the  production  of  abnormalities.  He 
shows  that  by  temporarily  lowering  the  temperature  and  thereby 
reducing  the  rate  of  oxidation,  or  by  directly  cutting  off  the  supply  of 
oxygen,  the  normal,  continuous  course  of  development  of  the  embryo 
or  of  some  embryonic  part  may  be  interrupted,  with  the  result  that 
characteristic  suppressions  or  distortions  may  occur.  Interruption  of 
development  during  late  cleavage,  for  example,  results  in  the  produc- 
tion of  a  considerable  number  of  twins  and  double  individuals. 

During  the  past  twenty  years  or  so  experimental  embryologists 
have  also  furnished  us  with  various  interesting  and  significant  facts 
concerning  the  origin  and  development  of  the  early  crystalline  lens. 
There  has  grown  up  through  their  efforts,  in  fact,  a  distinct  "lens- 
problem."  As  we  have  already  seen,  under  normal  conditions  the 
lens  develops  in  very  close  association  with  the  optic  cup.  The  ques- 
tion arose,  therefore,  as  to  whether  the  lens,  like  the  optic  cup,  was  in 
a  sense  a  self-differentiating  structure,  or  whether  it  owed  its  occur- 
rence to  a  contact-stimulus  exerted  by  the  optic  vesicle  upon  the  over- 
lying ectoderm.  The  belief  that  the  ectoderm  was  unable  to  give  rise 
to  a  lens  without  the  optic  vesicle  stimulus  was  experimentally  sup- 
ported by  the  early  work  of  Spemann  (1901,  1903)  and  Herbst  (1901). 
Spemann,  for  instance,  showed  that  injury  to  the  medullary  plate  of 
the  frog  (Rana  fusca)  might  inhibit  development  of  the  optic  cup,  or, 
if  the  cup  developed,  might  keep  it  from  coming  into  contact  with  the 
ectoderm.  In  either  event  no  lens  formed.  If,  however,  in  spite  of 
the  injury,  the  cup  or  even  a  part  of  it  reaches  the  epidermis,  a  lens 
forms  at  the  point  of  contact.  Lewis  (1904,  1907a,  1907b)  also,  from 
a  series  of  studies  on  other  species  of  frog  and  on  the  salamander 
(Amblystoma) ,  concluded  that  lens  would  not  arise  from  the  normal 


The  Production  and  Transmission  of  Certain  Eye  Defects      677 

lens-forming  region  of  the  ectoderm  without  the  contact-stimulus  of 
the  optic  vesicle  on  the  inner  layer  of  the  ectoderm.  He  showed, 
moreover,  that  a  piece  of  ectoderm  taken  from  another  part  of  the 
body  and  grafted  over  the  optic  cup  would  form  a  lens,  and  also  that 
the  optic  cup  experimentally  removed  and  engrafted  under  the  epi- 
dermis of  another  region  of  the  head  would  stimulate  the  development 
of  a  lens  at  any  point  of  the  surface-ectoderm  with  which  it  came  in 
contact.  Lewis  found,  furthermore,  that  the  optic  cup  of  one  species 
of  larval  amphibian  can  probably  even  stimulate  the  formation  of 
lens  from  the  ectoderm  of  another  species.  Thus,  optic  vesicles  of 
the  frog,  Rana  sylvatica,  were  transplanted  beneath  the  head-ectoderm 
of  salamander  embryos  (Amblystoma).  Lenses  were  later  found 
associated  with  several  of  the  transplanted  eyes.  He  was  not  abso- 
lutely sure  of  the  source  of  these  lenses,  but  as  the  amblystoma  embryos 
had  normal  lenses  in  their  own  eyes,  uninfluenced  by  these  secondary 
lenses,  the  inference  was  that  formation  of  the  latter  had  been  initiated 
by  the  transplanted  alien  optic  vesicles.  Spemann  reports  having 
secured  lens-formation  in  the  ventro-abdominal  ectoderm  of  Bom- 
binator,  by  transplanting  it  over  the  bared  optic  vesicle  of  Rana. 

From  the  various  experiments  just  related  it  is  obvious  that  epi- 
dermis that  does  not  normally  give  rise  to  lens  will  differentiate  into  a 
lens  if  brought  into  contact  with  the  optic  vesicle.  It  would  seem 
that  there  are  no  special  cells  predetermined  to  form  lens.  In  his 
later  papers,  however,  Spemann  (1908,  1912)  modifies  his  opinion 
somewhat  on  the  basis  of  other  experiments,  concluding  that  while 
in  some  species  of  frogs  lens  cannot  develop  if  the  optic  vesicle  fails 
to  make  contact  with  the  overlying  epidermis,  in  at  least  one  species 
the  epidermis  is  capable  of  engendering  lenses  without  such  contact. 
King  (1905)  and  Stockard  (1910),  furthermore,  maintain  on  the  basis 
of  their  experimental  work  that  there  can  be  independent  origin  and 
development  of  the  crystalline  lens. 

In  his  studies  of  the  problem,  Stockard  (1910)  substituted  chemical 
means  of  experimentation  for  the  mechanical  operations  employed  by 
other  investigators.  The  developing  eggs  of  the  minnow,  Fundulus 
heteroclitus,  were  subjected  for  a  time  to  the  action  of  magnesium  salts, 
alcohol  or  ether.  Such  treatment  frequently  prevented  the  outgrowth 
of  the  optic  vesicles.  In  this  way  he  secured  embryos  with  the  optic 
outgrowths  as  entirely  lacking  as  in  specimens  with  these  parts  cut 
out.  This  method  has  the  advantage  of  avoiding  the  injury  to  the 
ectoderm  which  results  from  mechanical  operation.  In  many  of  the 


678  M.  F.  GUYER 

fish  embryos  with  optic  outgrowths  thus  suppressed  by  chemical 
means,  he  found  developing  crystalline  lenses.  He  concluded,  there- 
fore, that  typical  lenses  may  originate  and  develop  from  ectoderm 
without  any  direct  stimulus  from  optic  vesicle  or  cup.  The  possi- 
bility that  optic  vesicles  may  have  arisen,  stimulated  the  formation 
of  lens  and  then  degenerated,  he  believed,  judging  from  the  hundreds 
of  Fundulus  embryos  he  has  studied,  is  entirely  out  of  the  question. 

Stockard  (1910b)  takes  the  ground,  therefore,  that  while  unques- 
tionably an  optic  vesicle  or  cup  possesses  power  to  induce  lens-forma- 
tion from  various  regions  of  the  ectoderm  with  which  it  may  come  in 
contact,  there  can  also  be  independent  formation  of  the  lens.  He 
believes  that  independent  lens-forming  power  is  present  over  the 
entire  head,  but  that  it  diminishes  from  before  backward  until  trunk- 
ectoderm  is  reached,  which  no  longer  possesses  this  capacity.  He 
maintains  that  when,  in  eyeless  larvae,  free  lenses  occur,  they  usually 
arise  near  the  anterior  tip  of  the  head.  Posterior  lenses  as  large  as 
anterior  ones  may  appear,  but  they  occur  less  frequently.  He  thinks 
that  the  ectoderm  of  the  head  has  a  distinct  tendency  to  form  lens 
but  that  it  exercises  this  capacity  much  more  certainly  and  effectively 
when  stimulated  by  optic  vesicle  or  optic  cup. 

In  a  later  critique  of  the  whole  lens  problem  Werber  (1918)  argues 
that  the  original  interpretation  which  regarded  actual  contact  of 
optic  outgrowth  with  the  ectoderm  as  essential  to  lens  formation  is 
the  correct  one.  In  experiments  based  on  extirpation  of  the  optic 
vesicles  or  optic  cups,  for  example,  he  maintains,  from  evidence  he 
finds  in  his  own  studies  (1916c),  that  fragmentation  of  the  optic 
vesicle  has  occurred,  so  that  bits  of  it  sufficient  to  stimulate  lens- 
formation  have  been  left  behind  and  he  thinks  that  the  same  thing  has 
probably  happened  in  the  operations  of  others.  In  teratological 
material,  likewise,  he  points  out,  there  is  frequently  much  dissociation 
and  shifting  of  tissues.  He  cites  a  case  in  his  own  experience  in  which 
the  optic  cup  became  profoundly  dissociated  and  scattered  so  that 
fragments  of  it  came  into  contact  with  the  ectoderm  of  the  head  in 
many  places,  with,  the  result  that  lentoid  bodies  were  formed  in  great 
numbers. 

In  the  face  of  the  amount  of  evidence  brought  forward  by  Stockard, 
however,  Werber's  arguments  against  independent  lens-formation  are 
not  very  convincing,  at  least,  as  regards  the  cases  of  chemically 
induced  monstrosities  in  Fundulus.  The  conclusion  that  ordinarily 
the  lens  arises  only  in  response  to  a  stimulus  from  the  optic  vesicle, 


The  Production  and  Transmission  of  Certain  Eye  Defects      679 

but  that  under  certain  conditions  it  can  arise  independently  seems  to 
be  the  most  justifiable  one  in  the  present  state  of  the  evidence. 

Experiments  have  shown  that  lens-formation  may  also  be  initiated 
in  or  by  later  derivatives  of  the  optic  cup.  Thus  the  epithelium  of 
the  iris  can  apparently  undergo  lens-formation,  as  can  also  the  retinal 
cells.  For  example,  when  the  lens  is  removed  in  certain  amphibia, 
a  new  lens  may  be  generated  from  the  margin  of  the  iris.  Wachs 
(1914)  found,  moreover,  that  when  he  implanted  a  fragment  of  iris  in 
the  vitreous  chamber  of  an  eye  deprived  of  its  lens,  the  implanted 
fragment  and  the  animal's  own  iris  each  formed  a  new  lens.  It  has 
also  been  shown  experimentally  that  retinal  cells  can  both  furnish  the 
stimulus  for  lens-formation  and  respond  to  it,  since  retinal  lentoids 
can  be  induced  to  form  by  experimental  injury  of  the  retina. 

It  is  an  interesting  fact  that  the  mechanical  effect  of  contact  may 
play  an  important  part  in  lens  "regeneration."  Fischel  (1902),  for 
example,  removed  the  lens  of  a  salamander  and  replaced  it  by  a  small 
spherical  bit  of  potato.  When  this  was  large  enough  to  fit  the  pupil, 
new  lens-formation  did  not  take  place,  but  if  the  diameter  of  the  foreign 
body  was  smaller  than  that  of  the  pupil,  an  attempt  toward  new  lens- 
formation  occurred.  More  recently  Fischel  (1916)  found,  in  larvae  of 
the  salamander  (Salamandramaculosa),when  the  extirpated  lens  was 
transplanted  under  the  skin  of  various  parts  of  the  head  or  trunk,  that 
while  the  lens  degenerated  more  or  less  and  tended  to  be  resorbed,  the 
overlying  skin  underwent  changes  which  eventually  led  to  its  becom- 
ing transparent  and  very  similar  to  a  cornea.  Wachs  (1914)  had 
earlier  obtained  much  the  same  result  with  a  transplanted  fragment 
of  the  optic  cup  containing  both  iris  and  retina.  Such  an  effect,  how- 
ever, is  probably  mechanical  and  not  adaptive,  as  would  appear  at 
first  sight,  since  Cole  (1922)  has  shown  that  although  tail-skin  grafts 
over  the  eyes  of  frog-tadpoles  become  absorbed  in  such  a  manner  as 
to  tend  to  expose  the  eyes  and  restore  vision,  absorption  also  occurs 
in  tail-skin  grafts  over  small  hemispheres  of  glass  or  celloidin.  Cole 
regards  such  absorption,  therefore,  not  as  functional  regulation,  but 
as  entirely  a  mechanical  reaction  to  the  tension  caused  by  the  curva- 
ture of  the  underlying  object. 

As  work  in  the  field  of  immunology  has  progressed  during  the  past 
quarter  of  'a  century  it  has  become  increasingly  evident  that  the 
serologic  reactions  all  have  their  broader  biologic  aspects.  They 
must  in  last  analysis  be  but  special  manifestations  of  the  general 
processes  which  underlie  all  life  phenomena.  Unquestionably  the 


680  M.  F.  GUYER 

serologist  has  put  important  tools  and  ideas  into  the  possession  of  the 
experimental  biologist  which  may  be  utilized  in  new  attacks  upon 
certain  fundamental  biological  problems. 

The  hemolysins,  for  example,  discovered  by  Bordet  in  1895,  are  now 
known  to  be  special  members  of  a  general  class  of  substances  termed 
cytotoxins  or  cytolysins.  For  just  as  alien  red  blood-cells  lead  to  the 
production  of  specific  hemolysins,  so  various  other  materials,  as 
leukocytes,  nervous  tissues,  spermatozoa  and  crystalline  lens — any 
foreign  protein,  in  fact — when  injected  into  the  blood-stream  of  an 
unrelated  species,  will  cause  the  formation  of  lytic  substances  more 
or  less  specific  for  the  antigen  used  in  the  immunizing  process.  All 
cytolytic  sera  so  far  studied  have  been  found  to  be  more  or  less  hemo- 
lytic,  and  it  is  probable  that  none  acts  exclusively  upon  its  own  antigen. 
While  a  particular  cytolytic  serum  may  affect  some  other  tissues,  it 
attacks  the  special  tissue  used  as  antigen  much  more  vigorously. 

Although  presumably  distinct  from  one  another,  the  various  classes 
of  the  so-called  antibodies — precipitins,  agglutinins,  bacteriolysins, 
cytolysins  or  cytotoxins,  etc. — seem  to  have  many  points  of  similarity, 
as,  for  instance,  their  method  of  origin,  their  reaction  to  heat,  and, 
in  some  cases,  their  mode  of  operation.  Chemically  their  natures  are 
still  unknown.  Considerable  evidence  of  their  close  association  in 
some  way  with  the  euglobulin  constituent  of  the  blood  is  appearing 
in  various  recent  researches. 

To  the  biologist  viewing  this  fascinating  field,  many  questions  arise. 
If,  for  example,  it  is  possible  to  originate  in  living  organisms  anti- 
bodies which  will  destroy  particular  tissue-elements,  is  it  not  possible 
to  secure  similar  selective  action  on  certain  parts  of  the  developing 
embryo?  May  not  serologic  methods  enable  us  to  make  a  new 
attack  upon  the  long-standing  problem  of  the  inheritance  of  somatic 
modifications,  or  that  of  provoking  specific  modifications  in  the  germ 
through  direct  operation  of  external  agents?  If  a  special  serum  can 
be  developed  which  will  single  out  and  destroy  a  certain  element  of 
the  adult,  is  it  not  possible  that  there  is  sufficient  constitutional 
identity  between  the  mature  substance  of  such  a  part  and  one  or  the 
other  of  its  material  antecedents  in  the  germ,  that  the  latter  may  also 
be  influenced  specifically  by  the  serum  in  question?  If  external  influ- 
ences can  be  transmitted  to  the  germ-cell,  it  is  clear  that  in  higher 
animals  the  one  obvious  means  of  conveyance  is  the  blood. 

In  an  attempt  to  find  answers  to  certain  questions  of  this  kind  I 
and  my  research  associate,  Dr.  E.  A.  Smith,  began  various  experi- 


The  Production  and  Transmission  of  Certain  Eye  Defects      681 

ments  some  six  years  ago  which  we  are  still  continuing.  Among  other 
things  we  undertook,  by  means  of  cytolysins,  to  produce  antenatal 
effects  in  fetuses.  Our  main  work  in  this  direction  has  been  on  rabbits 
with  fowl-serum  immunized  against  rabbit-lens,  although  we  have 
also  experimented  somewhat  with  mice  and  with  guinea-pigs.  I  shall 
confine  my  discussion  largely  to  certain  eye-abnormalities  we  secured 
in  fetal  rabbits,  and  to  the  inheritance  of  such  defects. 

In  our  first  experiments1  the  lenses  of  newly  killed  young  rabbits 
were  pulped  thoroughly  in  a  mortar  and  diluted  with  normal  salt 
solution.  About  four  cubic  centimeters  of  this  emulsion  was  then 
injected  intravenously  or  intraperitoneally  into  each  of  several  fowls. 
Four  or  five  weekly  treatments  with  such  lens-emulsions  were  given. 
A  week  or  ten  days  after  the  last  injection  the  blood-serum  of  the 
fowls  was  ready  for  use.  The  rabbits  had  been  so  bred  as  to  have 
their  young  advanced  to  about  the  tenth  day  of  pregnancy,  since 
from  the  tenth  to  the  thirteenth  day  seems  to  be  a  particularly  impor- 
tant period  in  the  development  of  the  lens.  As  we  saw  in  reviewing 
the  embryology  of  the  eye,  the  lens  is  then  growing  rapidly  and  is 
surrounded  by  a  rich  vascular  network  that  later  disappears.  From 
four  to  seven  cubic  centimeters  of  the  immunized  fowl-serum  were 
injected  intravenously  into  the  pregnant  rabbits  at  intervals  of  two  or 
three  days  for  from  ten  days  to  two  weeks.  A  number  of  the  rabbits 
died  from  the  treatment  and  many  young  were  killed  in  utero.  Of 
sixty-one  surviving  young  from  mothers  thus  treated,  four  had  one 
or  both  eyes  conspicuously  defective  and  five  others  had  eyes  that 
were  clearly  abnormal.  It  is  possible  that  still  others  were  more  or 
less  affected,  as  we  judged  only  by  conditions  easily  visible.  In  some 
of  the  descendants  of  this  stock,  indeed,  ophthalmologists  who  have 
examined  the  eyes  more  thoroughly  have  pointed  out  defects  which 
we  had  overlooked,  and  occasionally  rabbits,  that  in  their  earlier 
months  passed  for  normal,  have  later  manifested  defects  in  the  lens 
or  in  other  parts  of  the  eye. 

The  commonest  abnormality  seen  in  both  the  original  subjects  and 
in  their  numerous  descendants  was  partial  or  complete  opacity  of  the 
lens  (Plate  I,  Fig.  4),  usually  accompanied  by  reduction  in  size  of  the 
eye  (Plate  I,  Fig.  2).  In  a  few  of  our  later  strains  in  a  different  experi- 
ment, however,  we  have  had  several  cases  of  enlargement  of  the  eye, 
or  buphthalmia  (Plate  I,  Fig.  3) .  Among  the  rabbits  I  brought  with 
me  for  demonstration  there  is  one  of  this  type  which  I  shall  be  glad 
1  Guyer  and  Smith,  1918,  1920. 


682  M.  F.  GUYER 

to  have  you  examine.  Other  common  defects  which  have  appeared 
are  cleft-iris,  displacement  of  the  lens,  persistent  hyaloid  artery, 
bluish  or  silvery  color  instead  of  the  characteristic  pink  of  the  albino 
eye,  microphthalmia,  and  even  almost  complete  disappearance  of  the 
eyeball.  The  cases  of  cleft-iris,  or  coloboma,  range  all  the  way  from  a 
narrow  slit  in  the  lower  edge  of  the  iris  to  a  broad  wedge-  or  U-shaped 
opening  which  amounts  practically  to  the  absence  of  the  entire  lower 
part  of  the  iris.  The  cleft  may  be  confined  to  the  iris  or  it  may 
extend  back  deeper  into  the  eye.  When  one  takes  into  account  the 
early  embryology  of  the  eye,  it  is  easy  to  see  how  such  clefts  result 
from  failure  of  the  choroidal  fissure  to  close  as  it  should  do  normally. 
The  bluish  or  silvery  color,  I  am  told  by  ophthalmologists  who  have 
examined  the  rabbits,  is  due  mainly  to  detachment  of  the  retina. 
Here  again,  when  one  recalls  the  loose  embryologic  connection 
between  the  retinal  layers  of  the  eye  and  the  outer  coats,  even  in  the 
normal  eye,  it  is  easy  to  see  how  almost  any  distortion  of  the  eyeball, 
unevenness  of  growth,  or  accumulation  of  fluid  might  bring  about 
such  detachment. 

Many  of  the  eyes  take  abnormal  postures  (Plate  I,  Fig.  3).  This 
is  particularly  true  in  some  of  our  later  strains.  One  or  both  eyes  are 
likely  to  be  strongly  rotated  downward  or  backward.  The  backward- 
rotation  is  carried  to  such  an  extreme  in  some  cases  that  the  cornea  is 
visible  only  when  the  eyelids  are  drawn  back  at  the  outer  corner 
(Plate  I,  Fig.  3),  or  occasionally  when  the  animal  attempts  to  roll  its 
eyeball  forward.  In  such  eyes  the  exposed  sclera  in  front  usually 
bulges  (staphyloma)  and  becomes  transparent,  simulating  a  cornea. 
When  we  first  came  across  this  anomaly,  in  fact,  we  thought  that  we 
had  a  rabbit  with  a  double  eye  on  each  side.  I  have  brought  one  such 
individual  with  me  for  demonstration. 

Taking  into  account  the  method  of  embryologic  development — 
the  relations  of  lens,  optic  cup  and  choroidal  fissure — the  defects, 
except  those  of  the  muscular  attachment,  are  practically  all  such  as 
might  reasonably  be  attributed  to  arrests  of  development  based  upon 
early  lens-defect.  It  is  possible,  to  be  sure,  that  we  have  developed 
antibodies  against  other  eye-tissues  as  well  as  against  the  lens,  since 
undoubtedly  more  or  less  of  the  aqueous  humor  and  the  vitreous  body 
adhered  to  the  lenses  when  we  removed  and  pulped  them  for  the 
original  injections.  Moreover,  if  proteins  from  other  parts  of  the 
eye  are  ever  in  solution  in  the  humors,  they  too  may  have  been  present 
in  the  antigen.  Each  individual  protein,  of  course,  has  the  capacity 


The  Production  and  Transmission  of  Certain  Eye  Defects      683 
PLATE  I 


Fig.  1  Fig.  2 

Fig.  1. — Showing  appearance  of  normal  eye. 

Fig.  2.— Microphthalmic  eye  with  cleft  iris  and  opaque  lens;    eyeball  rotated 
downward  somewhat. 


Fig.  3  g  Fig.  4 

Fig.  3. — Buphthalmic  eye  with  staphylomatous  sclera.  The  eyeball  is  so  rotated 
backward  that  the  edge  of  the  cornea  is  just  visible  at  the  upper  outer  angle  of 
the  lids;  the  lenses  in  both  eyes  are  opaque. 

Fig.  4. — Showing  opaque  lens  and  coloboma  of  the  iris. 


684  M.  F.  GUYER 

for  engendering  antibodies  specific  for  itself.  Even  the  lens  is  composed 
of  at  least  four  proteins:  albuminoid  (constituting  the  lens-fibers), 
alpha-crystallin,  beta-crystallin  and  albumin.  According  to  Jess 
and  Reiss  (Jess,  1920),  in  their  study  of  the  chemical  changes  which 
take  place  in  cataract,  alpha-  and  beta-crystallin,  both  soluble  in 
water,  make  up  the  greater  part  of  the  lens  of  the  young  animal. 
These  gradually  decrease  in  quantity  with  age,  accompanied  by  sclero- 
sis— a  process  even  more  in  evidence  in  cataractous  lenses. 

In  some  of  our  animals  we  find  that  an  eye  defective  at  birth,  par- 
ticularly if  microphthalmic,  may  undergo  further  degeneration, 
characterized  by  collapse  of  the  eyeball  and  resorption,  so  that  the 
eyeball  may  eventually  disappear  entirely.  The  eyes  of  the  mothers 
originally  injected  have  always  remained  apparently  unaffected. 
This  is  probably  due  to  the  fact  that  the  lens-tissue  of  the  adult  is 
largely  a  vascular,  and  that,  therefore,  the  injected  antibodies  did  not 
come  into  contact  with  it. 

That  the  changes  in  the  eyes  of  the  fetuses  resulted  from  the  specific 
action  of  lens-antibodies  is  indicated  by  the  fact  that  in  the  original 
experiment,  in  not  one  of  the  forty-eight  controls  obtained  from 
mothers  which  had  been  treated  with  pure  fowl-serum  or  with  fowl- 
serum  immunized  to  rabbit-tissues  other  than  lens,  was  there  any 
evidence  of  eye-defects.  I  may  add  that  since  then,  among  over  five 
hundred  young  obtained  from  mothers  which  are  being  experimented 
upon  for  other  purposes  with  various  types  of  sera  or  protein-extracts, 
or  with  typhoid  bacilli,  just  before  or  during  pregnancy,  not  a  single 
case  of  eye-defect  has  appeared.  To  one  familiar  with  the  results 
obtained  by  the  experimental  embryologist,  which  show  how  suscep- 
tible the  eye  is  in  early  embryogeny  to  any  kind  of  harmful  influence, 
the  natural  inclination  is  to  regard  such  abnormalities  as  due  merely 
to  a  general  poisonous  or  inhibitive  effect,  rather  than  to  specific  anti- 
bodies in  the  blood-serum.  That  lens-defects  may  be  produced  by 
general  chemical  or  physical  means  is  undeniable.  I  know  of  no  case 
yet,  however,  where  they  have  become  inheritable.  Bagg  (1922),  for 
example,  has  recently  found  that  as  a  result  of  exposure  of  rats  to 
radium  emanation  (gamma-ray  radiation)  during  late  pregnancy, 
some  of  the  young,  after  birth,  developed  eye-defects.  In  his  paper 
he  gives  photographs  of  an  adult  in  which  both  lenses  have  become 
opaque  and  the  left  eyelids  nearly  closed.  As  a  rule,  such  fetally 
irradiated  young  showed  other  marked  defects,  particularly  of  the 
nervous  system,  and  were  usually  sterile. 


The  Production  and  Transmission  of  Certain  Eye  Defects      685 

Regarding  our  own  rabbits  I  can  only  repeat  that  we  have  never 
obtained  the  defects  in  question  except  with  serum  carrying  specific 
antibodies.  In  any  event,  should  the  effect  have  originally  been  a 
general  rather  than  a  specific  one,  it  is  obvious  that,  germinally  con- 
sidered, it  must  sooner  or  later  have  become  specific,  since  the  anoma- 
lous eye-condition  appears  generation  after  generation  without  any 
recognizable  accompanying  malformations  of  other  parts  of  the  body. 

Before  passing  on  to  the  question  of  inheritance,  I  may  say  that  by 
way  of  control,  for  genetical  studies,  in  addition  to  what  we  have 
termed  our  3A1  line,  we  developed  another  line  from  wholly  unrelated 
stock,  our  so-called  16A1  line.  Moreover,  we  have  established  still  a 
third  strain,  the  84  line,  which  was  started,  not  by  means  of  fowl- 
serum  immunized  to  rabbit-lens,  but  by  the  use  of  pulped  rabbit -lens 
intravenously  injected  directly  into  rabbits  just  before  or  during  their 
pregnancy.  In  this  last  case  the  rabbit  must  herself  have  developed 
antibodies  against  the  invading  lens-material.  Out  of  eleven  different 
females  so  treated,  in  twenty-three  matings,  only  one  individual  gave 
us  young  with  abnormal  eyes.  These  defects  are  of  the  same  general 
nature  as  those  secured  by  means  of  fowl-serum  immunized  to  rabbit- 
lens,  and  they  behave  similarly  in  inheritance. 

As  already  indicated,  once  the  defect  is  secured,  it  may  be  trans- 
mitted to  subsequent  generations  through  breeding  (Fig.  1).  So  far, 
in  the  3A1  line,  we  have  succeeded  in  passing  it  down  through  nine 
generations.  There  is  no  reason  apparent  why  it  will  not  go  on  indefi- 
nitely, since  the  imperfections  tend  to  become  worse  in  successive 
generations,  and  also  to  occur  in  a  proportionately  greater  number  of 
young.  The  same  genetical  conditions  hold  for  the  other  lines, 
although  because  of  their  more  recent  origin,  we  have  manifestly  not 
been  able  to  carry  them  through  so  many  generations. 

The  transmission  is  not  infrequently  of  an  irregular  unilateral  type 
(Fig.  1),  sometimes  only  the  right,  at  others  only  the  left,  eye»showing 
the  defect.  In  this  respect  it  resembles  genetically  such  anomalies 
as  brachydactyly  or  polydactyly  in  man.  In  later  generations  there 
has  been  an  increasing  number  of  young  with  both  eyes  affected. 

Though  not  analyzed  completely  as  to  its  exact  mode  of  inheritance, 
the  abnormal  condition  has  in  general  the  characteristics  of  a  Mende- 
lian  recessive.  When  either  defective-eyed  males  or  females  are  bred 
to  normal-eyed  individuals  from  other  strains,  for  instance,  only 
normal-eyed  progeny  result  in  the  first  generation,  but  the  abnormal 
condition  may  be  made  to  reappear  in  subsequent  generations  if 


688 


M.  F.  GUYER 


appropriate  matings  are  made.     If  we  were  dealing  with  a  pair  of 
simple  Mendelian  characters,  the  young  from  two  individuals  with 


si'tif  i  *i5 
•ZtUHiili 


•O  S^£  «'£ 
&P     '"  ^  -S'S  « 


Oj'oQ  ^^>J«»,  ' 


the  same  recessive  trait  should  all  show  this  trait.    Two  of  our 
defective-eyed  rabbits,  however,  when  bred  together,  are  likely  to 


The  Production  and  Transmission  of  Certain  Eye  Defects      687 

produce  some  normal-eyed  young.  If,  therefore,  this  inheritance  is 
to  be  interpreted  in  terms  of  Mendelism,  there  is  probably  more  than 
one  pair  of  unit-factors  involved. 

To  meet  the  objection  that  we  are  not  getting  instances  of  true 
inheritance  but  merely  placental  transmissions  of  antibodies  or  related 
substances  from  the  blood-stream  of  the  mother  in  each  successive 
generation,  we  have  established  the  descent  through  the  male  line  in 

Line  Extractions 


n 


I    26AZ/Z6/I7  Z6A6 


2.8A4 


Fig.  2. — Inheritance  of  the  defects  through  the  male  line.  It  is  plain  that  indi- 
viduals of  the  32B,  46A  and  61A  series  could  have  derived  their  defects  only  from 
male  ancestry  originally,  since  female  17  was  of  normal  and  unrelated  stock. 
Symbols  same  as  in  Fig.  1. 

a  number  of  cases,  one  of  which  is  represented  in  Fig.  2.  To  do  this, 
females  from  strains  of  rabbits  unrelated  to  our  treated  stock  were 
mated  to  defective-eyed  males.  The  first  generation  produced  in 
this  way  was  invariably  normal-eyed ;  that  is,  the  defective  condition 
was  recessive  to  normal  condition.  When,  however,  females  of  this 
generation  were  mateS  to  defective-eyed  males,  or  to  normal-eyed 
males  of  similar  derivation  to  themselves,  the  defects  reappeared  in 


688  M.  F.  GUYER 

some  of  the  progeny,  somewhat  after  the  manner  of  an  extracted 
Mendelian  recessive.  It  is  obvious  that  the  normal  condition  could 
have  been  introduced  into  these  new  strains  only  through  the  germ- 
cells  of  the  males,  and  that  its  transmission  is,  therefore,  an  example 
of  true  inheritance. 

I  feel  that  in  establishing  and  developing  from  unrelated  stock 
three  different  strains  of  defective-eyed  rabbits — two  (3A1  line  and 
16 A 1  line)  by  the  use  of  fowl-serum  immunized  to  rabbit-lens,  the 
other  (84  line)  by  direct  injection  of  rabbit-lens  into  a  pregnant  rabbit 
— we  have  placed  our  results  beyond  the  bounds  of  coincidence  or 
chance.  We  can  also  cite  further  the  production  recently  of  similar 
lens-defect  in  the  young  of  the  guinea-pig,  if  need  be,  although  we  are 
not  yet  ready  to  report  on  this  latter  series  of  experiments. 

To  the  biologist,  perhaps  the  most  interesting  fact  brought  to  light 
in  these  researches  is  the  possibility  of  directly  or  indirectly  inducing 
germinal  changes  by  means  of  antibodies  developed  in  an  animal's 
own  body  against  tissues  taken  from  individuals  of  the  same  species. 
Such  a  result  together  with  another  I  have  obtained  in  inducing  the 
male  rabbit  to  develop  spermatotoxins  against  its  own  spermatozoa 
(Guyer,  1922a),  lend  support  to  the  idea  that  an  animal  can  build 
antibodies  against  its  own  tissues  when  these  are  misplaced,  altered 
or  injured,  and  that  such  antibodies  may  so  affect  the  germ-cells  as  to 
induce  germinal  changes.  Since  I  have  discussed  this  point  rather 
fully  in  recent  papers  (Guyer,  1921,  1922b,  1922c),  I  need  not  enter 
into  it  here. 

LITERATURE  CITED 

Child,  C.  M.  Individuality  in  Organisms.  University  of  Chicago  Press,  1915. 
The  Origin  and  Development  of  the  Nervous  System.  University  of 
Chicago  Press,  1921. 

Cole,  W.  H.  The  Transplantation  of  Skin  in  Frog  Tadpoles,  with  Special 
Reference  to  the  Adjustment  of  Grafts  over  Eyes  and  to  Local  Specificity 
of  Integument.  Jour.  Exp.  Zool.,  v.  35,  no.  4,  May,  1922. 

Fischel,  A.  Weitere  Mitteilungen  iiber  die  Regeneration  der  Linse.  Arch.  f. 
Entw.-Mech.,  v.  15,  1902.  Uber  riicklaufige  Entwicklung,  Arch.  f.  Entw.- 
Mech.,  v.  42,  1916. 

Guyer,  M.  F.  Immune  Sera  and  Certain  Biological  Problems.  Am.  Nat.,  v. 
55,  Mar.-Apr.,  1921.  Studies  on  Cytolysins:  Experiments  with  Sperma- 
totoxins. Jour.  Exp.  Zool.,  v.  35,  No.  2,  Feb.,  1922.  Serological  Reac- 
tions as  a  Probable  Cause  of  Variation.  Am.  Nat.,  v.  56,  Jan.-Feb.,  1922. 
Orthogenesis  and  Serological  Phenomena.  Am.  Nat.,  v.  56,  Mar.-Apr., 
1922. 


The  Production  and  Transmission  of  Certain  Eye  Defects      689 

Guyer,  M.  F.,  and  Smith,  E.  A.  Studies  on  Cytolysins:  Some  Prenatal  Effects 
of  Lens  Antibodies.  Jour.  Exp.  Zool.,  v.  26,  No.  1,  May,  1918.  Studies 
on  Cytolysins:  Transmission  of  Induced  Eye  Defects.  -Jour.  Exp.  Zool., 
v.  31,  No.  2,  Aug.,  1920. 

Herbst,  C.     Formative  Reize  in  der  tierischen  Ontogenese,  1901. 

Jess,  A.  Die  Monoaminosauren  der  Linsenproteine.  Ztschr.  f.  physiol.  Chem., 
110,  266,  1920. 

King,  H.  D.  Experimental  Studies  on  the  Eye  of  the  Frog  Embryo.  Arch.  f. 
Entw.-Mech.,  v.  19,  1905. 

Lewis,  W.  H.  Experimental  Studies  on  the  Development  of  the  Eye  in  Amphibia. 
Am.  Jour.  Anat.,  v.  3,  1904.  Experimental  Studies,  etc.  .  .  .  On 
the  Origin  and  Differentiation  of  the  Lens.  Am.  Jour.  Anat.,  v.  6,  1907. 
Lens  Formation  from  Strange  Ectoderm  in  R.  Sylvatica.  Am.  Jour. 
Anat.,  v.  7,  1907. 

Speman,  H.  tJber  Correlationen  in  der  Entwickelung  des  Auges.  Verh.  Anat. 
Ges.,  Anat.  Anz.,  v.  19,  Erganzungsbd.,  1901.  Uber  Linsenbildung  bei 
defekter  Augenblase.  Anat.  Anz.,  v.  23,  1903.  Neue  Versuche  zur  Ent- 
wicklung  des  Wirbeltierauges.  Verh.  d.  deutsch.  Zool.  Ges.  (Stuttgart), 
1908.  Zur  Entwicklung  des  Wirbeltierauges.  Zool.  Jahrb.,  Abt.  f.  allg. 
Zool.  u.  Physiol.,  v.  32,  1912. 

Stockard,  C.  R.  The  Development  of  Artificially  Produced  Cyclopean  Fish. 
Jour.  Exp.  Zool.,  v.  6,  1909.  The  Independent  Origin  and  Development 
of  the  Crystalline  Lens.  Am.  Jour.  Anat.,  v.  10,  1910.  An  Experimental 
Study  of  the  Optic  Anlage  in  Amblystoma  punctatum,  with  a  Discussion 
of  Certain  Eye  Defects.  Am.  Jour.  Anat.,  v.  15,  1913.  The  Artificial 
Production  of  Structural  Arrests  and  Racial  Degeneration.  Proc.  N.  Y, 
Path.  Soc.,  N.S.,  v.  13,  1914.  Developmental  Rate  and  Structural  Ex- 
pression: an  Experimental  Study  of  Twins,  Double  Monsters  and  Single 
Deformities,  etc.  Am.  Jour.  Anat.,  v.  28,  1921. 

Wachs,  H.  Neue  Versuche  zur  Wolff'schen  Linsenregeneration.  Arch.  f.  Entw.- 
Mech.,  v.  39,  1914. 

Werber,  E.  I.  Critical  Notes  on  the  Present  Status  of  the  Lens  Problem.  Biol. 
Bull.,  v.  34,  No.  4,  April,  1918. 


44 


A  NEW  TECHNIC  FOR  THE  APPLICATION  OF  THE 

METHOD  OF  CAJAL  TO  SECTIONS  OF 

THE  RETINA1 

DR.  FELIX  FERNANDEZ  BALBUENA 

Gijon,  Spain 

1.  Rolling  up  the  Retina  Around  the  Optic  Disc. — If  the  animals  are 
small,  we  leave  the  retinal  block  resulting  from  the  rolling  up  adher- 
ing by  means  of  the  optic  nerve  to  a  round  segment  of  the  eyeball.     In 
the  large  retinae  of  the  bull  or  sheep  we  make  several  blocks,  in  order 
to  facilitate  the  penetration  of  the  fixation  fluid. 

2.  Fixation  of  the  retinal  blocks  in  absolute  alcohol  (50  c.c.)  with 
pyridin  (5  to  10  c.c.),  according  to  formula  2aB  of  Cajal.     We  also 
use  the  absolute  alcohol  alone,  and  ammoniacal  alcohol,  as  in  the 
classic  method.     The  retinal  blocks  remain  in  the  fixation  fluid  twelve, 
twenty-four,  or  forty-eight  hours,  according  to  the  thickness  of  the 
specimens. 

3.  When  the  specimens  are  once  fixed,  they  are  enclosed  in  celloidin 
and  mounted  on  corks.     They  are  then  immersed  in  70  per  cent, 
alcohol  and  the  sensibilization  of  the  specimens  is  ascertained.     The 
blocks  mounted  on  cork  should  remain  in  70  per  cent,  alcohol  from  a 
few  days  to  two  or  three  months. 

The  best  results  are  usually  obtained  within  the  first  month.  This 
third  operation  is  usually  decisive.  We  call  it  provisionally  sensibili- 
zation of  the  retinal  block,  since  it  appears  that,  without  a  more  or 
less  prolonged  impregnation  of  the  blocks  in  70  per  cent,  alcohol,  the 
succeeding  steps  of  nitration,  developing,  and  fixing  of  the  sections 
will  be  failures. 

4.  Impregnation  of  the  Sections  in  a  Nitrate  of  Silver  Solution. — After 
the  retinal  blocks  have  undergone  the  impregnation  process  described, 
sections  are  made  which  are  grasped  with  a  paint-brush  and  deposited 
on  the  bottom  of  a  porcelain  or  glass  vessel  still  moistened  with  the 
alcohol  which  we  have  used  for  lubricating  the  blade  of  the  micro- 
tome; then  5  c.c.  or  more  of  a  1 : 2000  silver  nitrate  solution  to  which 

1  Special  demonstration  at  the  Army  Medical  Museum. 
690 


A  New  Technicfor  the  Application  of  the  Method  of  Cajal     691 

a  few  drops  of  pyridin  (5  or  10  drops — 20  c.c.)  have  been  added,  are 
poured  over  the  sections. 

When  the  sections  are  saturated,  we  slowly  heat  the  solution  until 
a  slight  steam  rises,  whereupon  we  let  the  solution  cool  off. 

Sometimes  it  happens  that  the  section  does  not  assume  a  yellow 
color,  as  is  the  case  when  the  conditions  are  favorable  to  impregna- 
tion. In  such  cases  the  solution  is  heated  several  times  until  the 
yellow  color  appears.  Generally  three  to  ten  minutes  of  embedding 
in  the  nitrate  of  silver  bath  are  sufficient. 

5.  Preparation  of  the  Colloid  Medium  and  Developing  of  the  Sections. — 
Three  or  four  drops  of  tincture  of  yellow  amber  added  to  the  nitrate 
of  silver  bath  impart  to  the  solution  a  colloid  consistence.     Afterward 
two  or  three  drops  of  a  1  per  cent,  hydroquinone  solution  are  added, 
at  the  same  time  shaking  the  vessel  to  render  the  mixture  homo- 
geneous. 

When  the  reaction  is  favorable,  a  gradual  deepening  of  the  color  of 
the  sections  and  a  clear  differentiation  of  the  various  regions  are 
noticed.  The  time  in  which  the  sections  remain  in  the  developing 
fluid  varies  from  four  to  ten  minutes.  By  watching  the  effects  we 
find  when  we  have  to  terminate  the  process.  By  some  calculation  we 
easily  arrive  in  each  case  at  the  desired  results.  In  some  cases  it  is 
necessary  to  assist  the  reaction  by  slow  heating  on  the  alcohol  lamp. 

6.  Fixation. — When  the  sections  are  developed,  they  are  washed  in 
the  same  vessel  with  distilled  water.     Then  we  pour  on  them  a  1 
per  cent,  borax  solution  and  three  or  four  drops  of  a  1  per  cent, 
yellow  chlorid  of  gold  solution.     We  finish  the  process  by  fixation  in 
a  5  per  cent,  hyposulphite  solution. 


AN  INTERNATIONAL   CONGRESS   OF 
OPHTHALMOLOGY 


MINUTES  OF  THE  PROCEEDINGS 


The  first  session  was  called  to  order  in  Colonial  Hall  of  the  Daugh- 
ters of  the  American  Revolution,  by  the  Chairman  of  the  Committee 
on  Arrangements,  Dr.  W.  H.  Wilmer,  Washington,  D.  C.,  and  an 
address  of  welcome  was  made  by  Hon.  Calvin  D.  Coolidge,  Vice- 
President  of  the  United  States. 

After  roll  call  of  delegates  to  the  Congress  the  committee  appointed 
to  nominate  permanent  officers  of  the  Congress  made  its  report, 
which  was  unanimously  adopted,  and  the  officers  named  were  de- 
clared elected  (page  5). 

The  Committee  of  Arrangements  made  the  following  report: 

Owing  to  the  fire  at  the  Hotel  Willard  it  has  been  necessary  to  make  ex- 
tensive changes  in  the  plans  for  the  Congress.  The  scientific  sessions  and  the 
evening  addresses  will  be  held  in  Colonial  Hall,  Daughters  of  the  American 
Revolution. 

On  Tuesday  afternoon  there  will  be  an  official  trip  to  Mount  Vernon  by 
trolley.  A  wreath  will  be  placed  upon  the  tomb  of  Washington. 

On  Tuesday  evening,  at  the  Corcoran  Gallery  of  Art,  the  President  and  the 
Officers  of  the  Congress  will  hold  a  reception  in  honor  of  the  members  of  the 
Congress  and  ladies. 

On  Wednesday  afternoon  the  President  of  the  United  States  will  receive 
the  members  of  the  Congress  and  ladies  at  the  White  House. 

Members  may  also  visit  the  Pan  American  Union  Building,  the  Army 
Medical  Museum,  Library  of  Congress,  and  other  places  of  interest. 

On  Thursday  afternoon  there  will  be  an  official  visit  to  the  Bureau  of 
Standards,  and  demonstrations  will  be  given  at  the  Army  Medical  Museum. 

On  Friday  evening  a  banquet  will  be  held  at  the  Hotel  Willard. 

The  Report  of  Committee  on  Scientific  Business  was  as  follows: 

The  Report  of  the  Committee  on  Scientific  Business  consists  of  the  pre- 
session  volume,  which  most  of  you  have  received,  and  the  program  of  over 
one  hundred  pages.  This  was  possible  only  through  the  co-operation  of 
another  committee,  the  Committee  on  Publication,  who  have  most  nobly 

692 


Minutes  of  the  Proceedings  693 

carried  on  our  work.    The  third  part  of  our  work  is  the  Daily  Bulletin,  which 
will  be  ready  for  distribution  each  morning. 

The  work  of  securing  a  scientific  program  has  been  arduous,  but  it  has 
been  a  most  grateful  task,  one  which  has  brought  us  into  communication  with 
some  of  the  great  men  in  ophthalmology  of  our  age,  and  we  hope  to  share  with 
all  the  members  of  the  Congress  an  even  more  intimate  communication  in  the 
three  days  that  are  to  come. 

THE  PKESIDENT:  We  will  now  proceed  with  the  scientific  discussions.  The 
first  paper  is  entitled  "Des  Enseignements  de  la  Guerre  en  Chirurgie  Ocu- 
laire"  (Teachings  of  the  War  in  Ocular  Surgery),  by  Prof.  F.  de  Lapersonne, 
of  Paris. 

The  paper  of  Prof,  de  Lapersonne  was  discussed  by  Drs.  Frederick  T. 
Tooke,  George  S.  Derby,  Allen  Greenwood,  G.  F.  Rochat,  Edmond  E. 
Blaauw,  and  Prof.  F.  de  Lapersonne. 

The  paper  of  Sir  William  Lister,  on  "Detachment  of  the  Vitreous,"  was 
read  by  Mr.  E.  Treacher  Collins,  who  said:  I  first  of  all  have  to  express  to 
you  Sir  William  Lister's  sincere  regret  that  he  is  unable  to  be  present.  The 
state  of  his  health  prevented  his  undertaking  the  journey.  When  he  asked 
me  to  read  an  abstract  of  his  paper  I  undertook  to  do  so  with  a  light  heart 
because  I  felt  sure  that  any  deficiency  which  there  might  be  on  my  part 
would  be  fully  compensated  for  by  the  beautiful  lantern  slides  which  he  had 
given  me  .to  show. 

The  paper  of  Sir  William  Lister  was  discussed  by  Drs.  Marcus  Feingold, 
Thomas  B.  Holloway,  John  E.  Weeks,  J.  W.  Nordenson,  Ignacio  Barraquer, 
F.  Park  Lewis,  F.  H.  Verhoeff,  Col.  R.  H.  Elliot,  Mr.  E.  Treacher  Collins 
and  Prof.  E.  Gallemaerts. 

The  next  paper  was  read  by  Prof.  Allvar  Gullstrand,  of  Upsala,  Sweden, 
on  "On  Diaphragm  Lamps  in  Ophthalmology." 

The  paper  of  Prof.  Gullstrand  was  discussed  by  Drs.  Edward  Jackson, 
Harry  S.  Gradle,  E.  E.  Blaauw,  G.  F.  Rochat  and  Prof.  Allvar  Gullstrand. 

The  paper  by  Dr.  Jose"  de  Jesus  Gonzalez,  of  Mexico,  on  "Sintomas  Ocu- 
lares  del  Envenenamiento  por  el  Piquete  de  Alacran "  (Ocular  Symptoms  of 
Poisoning  by  the  Sting  of  a  Scorpion),  was  read  by  Dr.  J.  M.  Penichet. 

The  paper  of  Dr.  Gonzalez  was  discussed  by  Drs.  Francisco  M.  Fernandez, 
Aurelio  Beraun,  Lloyd  Mills,  and  Col.  R.  H.  Elliot. 

At  the  conclusion  of  the  paper  of  Dr.  Gonzalez  the  Congress  adjourned. 


WEDNESDAY  MORNING,  APRIL  26,  1922 

The  Congress  was  called  to  order  by  the  President,  Dr.  George  E. 
de  Schweinitz. 

Dr.  S.  Gemblath,  of  Paris,  read  a  paper  on  "Traitement  du  Trachome  par 
les  Injections  sous  Conjonctivales  de  Cyanure  de  Mercure"  (Treatment  of 
Trachoma  by  Subconjunctival  Injections  of  Mercury  Cyanid). 


694  Minutes  of  the  Proceedings 

The  paper  of  Dr.  Gemblath  was  discussed  by  Drs.  Jesus  M.  Penichet, 
Joseph  Krimsky,  John  McMullen,  Lucien  Howe,  Prof.  F.  de  Lapersonne,  and 
Dr.  Said  Gemblath. 

The  President  announced  the  following  members  on  the  committees  to 
take  in  charge  the  consideration  of  propositions  which  were  brought  before 
the  Congress  for  action,  with  the  understanding  that  they  should  divide  their 
energies  between  the  three  problems: 

The  Value  of  Letters  and  Characters  as  Visual  Tests: 
Dr.  Edward  Jackson,  Denver,  Colorado. 
Dr.  A.  E.  Ewing,  St.  Louis,  Mo. 
Dr.  G.  F.  Rochat,  Groningen,  Holland. 
Ophthalmic  versus  Anatomic  Nomenclature : 
Dr.  M.  Uribe  Troncoso,  New  York  City. 
Dr.  M.  Feingold,  New  Orleans. 
Dr.  J.  W.  Nordenson,  Stockholm,  Sweden. 
Standards  for  Field  Taking: 

Col.  Robert  H.  Elliot,  London,  England. 
Dr.  Luther  C.  Peter,  Philadelphia,  Pa. 
Dr.  A.  Magitot,  Paris,  France. 
Prof.  C.  E.  Ferree,  Bryn  Mawr,  Pa. 

THE  PRESIDENT:  It  is  the  Chair's  understanding  that  these  three  com- 
mittees are  combined  in  one,  each  section  having  its  special  duty.  A  report 
will  be  made  which  shall  be  regarded  as  a  preliminary  one.  A  more  ex- 
tended study  will  be  reported  at  a  future  Congress.  The  Chair  suggests 
that  the  Secretary  of  the  Congress,  himself  the  author  of  one  of  the  propo- 
sitions, shall  be  requested  to  communicate  with  the  various  members  as  to 
their  meetings. 

The  Chair  has  the  honor  to  ask  the  senior  Vice-President  of  the  Congress, 
Dr.  Lucien  Howe,  to  take  the  chair. 

DR.  LUCIEN  HOWE:  The  next  paper  on  "Anomalies  of  Ocular  Develop- 
ment and  Pigmentation:  1.  Bilateral  Symmetric  Congenital  Corectopia  with 
Iridodonesis  and  Microcoria;  Microlentis  and  Coloboma  Lentis.  2.  Melan- 
osis  of  the  Eye,  Skin  of  Right  Side  of  Head,  and  Right  Palate,"  will  be 
presented  by  Mr.  J.  Gray  Clegg,  of  Manchester,  England. 

The  paper  of  Dr.  Clegg  was  discussed  by  Mr.  E.  Treacher  Collins  and  Drs. 
E.  E.  Blaauw,  Edward  Jackson,  and  J.  Gray  Clegg. 

DR.  LUCIEN  HOWE:  The  next  paper,  "Bitemporal  Contraction  of  Visual 
Fields  in  Pregnancy,"  will  be  presented  by  Prof.  C.  E.  Finlay,  of  Havana, 
Cuba. 

The  paper  of  Prof.  Finlay  was  discussed  by  Drs.  Walter  B.  Lancaster, 
Maud  Carvill,  and  Profs,  de  Lapersonne  and  Finlay. 

The  President,  Dr.  de  Schweinitz,  then  took  the  Chair,  and  announced 
that  the  next  paper  on  the  scientific  program  was  "Les  Echanges  d'Eau  et 
d'lons  a  Travers  la  Corne"e,"  by  Dr.  V.  Morax,  of  Paris.  Dr.  Weeks  stated 


Minutes  of  the  Proceedings  695 

that  Dr.  Morax  was  unable  to  attend  on  account  of  illness  in  his  family, 
but  that  he  wished  to  convey  his  greetings  to  the  members  of  the  Congress 
and  to  express  his  regrets  and  his  apologies  for  his  inability  to  be  here. 

The  next  paper  was  by  Dr.  Francisco  Poyales,  of  Madrid,  entitled  "La 
Tuberculosis  Ocular  InfantiP'  ("Infantile  Ocular  Tuberculosis"). 

The  paper  of  Dr.  Poyales  was  discussed  by  Drs.  W.  C.  Finnoff,  J.  Gray 
Clegg,  Ignacio  Barraquer,  H.  H.  Stark,  John  E.  Weeks,  E.  Treacher  Collins, 
Richard  Kerry,  F.  H.  Verhoeff,  and  Francisco  Poyales. 

Prof.  F.  de  Lapersonne,  of  Paris,  at  the  request  of  the  President,  took 
the  Chair  and  announced  the  paper  of  Dr.  C.  F.  Harford,  of  Cambridge,  on 
"  Psychopathology  in  Ophthalmic  Practice,"  which  was  read  by  Mr.  J.  Gray 
Clegg. 

The  paper  of  Dr.  Harford  was  discussed  by  Drs.  George  F.  Keiper  and 
J.  Gray  Clegg. 

Dr.  B.  Castresana,  of  Madrid,  was  not  present  to  read  his  paper  entitled 
"Nuevo  Tratamiento  Quirurgico  del  Estrabismo"  ("Treatment  of  Stra- 
bismus by  a  New  Surgical  Procedure"). 

Dr.  E.  Campodonico,  Lima,  Peru,  was  not  present  to  read  his  paper  en- 
titled "A  New  Procedure  in  the  Excision  Method  of  Pterygium  Operation." 

Dr.  S.  Lewis  Ziegler,  Philadelphia,  read  a  paper  entitled  "The  Subcon- 
junctival  Excision  of  Pterygium." 

The  papers  of  Drs.  Campodonico  and  Ziegler  were  discussed  by  Drs. 
John  0.  McReynolds,  A.  E.  Prince,  and  S.  Lewis  Ziegler. 


WEDNESDAY  AFTERNOON,  APRIL  26,  1922 

By  the  permission  and  courtesy  of  Brig.-Gen.  Robert  E.  Noble  the 
following  demonstrations  were  given  at  the  Army  Medical  Museum, 
the  arrangements  being  in  charge  of  Mayor  G.  R.  Callender. 

APPARATUS  AND  METHODS  OF  EXAMINATIONS 

MR.  E.  TKEACHER  COLLINS,  London,  England:  Lantern  Slide  Demonstra- 
tion. 

PROF.  ALLVAR  GULLSTRAND,  Upsala,  Sweden:  Diaphragm  Illumination. 

DR.  J.  W.  NORDENSON,  Stockholm,  Sweden:  Centric  Photography  of  the 
Fundus  Oculi. 

PROF.  I.  BARRAQUER,  Barcelona,  Spain:  Moving  Pictures  of  the  Operation  of 
Extraction  of  Cataract  in  the  Capsule. 

COL.  ROBERT  H.  ELLIOT,  M.D.,  London,  England:  The  Elliot  Sign  of  Glau- 
coma. 

DR.  GEORGE  MACKAY,  Edinburgh,  Scotland:  Clockwork  and  Cable  Tre- 
phines. 

DR.  JOHN  A.  McCAW,  Denver,  Col.:  A  Rotating  Campimeter  for  Mapping 
Paracentral  Scotomas. 

LUTHER  C.  PETER,  M.D.,  Philadelphia,  Pa.:  Perimetry. 


696  Minutes  of  the  Proceedings 

DR.  J.  ELLIS  JENNINGS,  St.  Louis,  Mo. :  Improved  Test  for  Color-Blindness. 
DR.  W.  H.  CRISP,  Denver,  Col. :  Photographic  Demonstration  of  Crossed  Cyl- 
inder Test  for  Astigmatism. 

PATHOLOGIC  SPECIMENS  AND  MICROSCOPIC  SLIDES 

Exhibit  from  the  Museum  of  the  American  Academy  of  Ophthalmology  and 

Oto-Laryngology. 
MR.  J.  GRAY  CLEGG,  Manchester,  England :  Miscellaneous  Specimens  for  Self 

and  Colleagues. 
PROF.  W.  GORDON  M.  BYERS,  Montreal,  Canada:  Acute  Tubercular  Uveo- 

keratitis. 
PROF.  M.  F.  GUYER,  Madison,  Wis.:   Experimental  and  Transmitted  Eye 

Defects. 
DR.  LUCIEN  HOWE,  Buffalo,  N.  Y. :  Eyes  of  Rabbits  in  Which  Hereditary 

Blindness  Has  Been  Produced. 
PROF.  ALBERTS  DEL  MONTE,  Naples,  Italy:   Protozoan  Bodies  Discovered 

and  Demonstrated  in  Chalazion. 
DR.  FELIX  F.  BALBUENA,  Gijon,  Spain:  A  New  Technic  for  the  Application 

of  the  Method  of  Cajal  to  Sections  of  the  Retina. 
DR.  F.  H.  VERHOEFF,  Boston,  Mass. :  a.  Characteristic  Lesions  and  Organisms 

(Leptothrices)  of  Parinaud's  Conjunctivitis;   b.  Microscopic  Specimen  of 

Coralliform  Cataract  Showing  Protein  Crystals  in  the  Lens;    c.  Micro- 
scopic Specimen  of  Asteroid  Hyalitis. 
DR.  E.  V.  L.  BROWN,  Chicago,  111.:   Massive  Band  of  Connective  Tissue 

Surrounding  the  Choroidea  in  a  Traumatized  Shrunken  Eye. 
DR.  W.  C.  FINNOFF,  Denver,  Col.:  Tuberculosis  as  It  Appears  in  the  Eye. 
DR.  CASEY  A.  WOOD  and  LIEUT.-COL.  F.  H.  GARRISON:    An  exhibit  of 

books  of  historic  interest  to  ophthalmologists  arranged  in  the  Library  of 

the  Surgeon-General's  Office. 
DR.  A.  MAGITOT  demonstrated  in  the  auditorium  of  the  Corcoran  Art  Gallery 

a  series  of  Lantern  Slides  Showing  Development  of  the  Human  Eye. 


•     WEDNESDAY  EVENING,  APRIL  26,  1922 

The  Congress  met  at  the  Colonial  Hall,  and  the  following  addresses 
were  delivered: 

PROF.  S.  E.  WHITNALL,  McGill  University,  Montreal,  "Some  Descriptive 

Errors  in  the  Anatomy  of  the  Orbit." 
PROF.  J.  PARSONS  SCHAEFFER,  Jefferson  Medical  College,  Philadelphia,  "On 

the  Clinical  Anatomy  of  the  Efferent  Lacrimal  Passageways." 

THURSDAY  MORNING,  APRIL  27,  1922 

The  Congress  was  called  to  order  by  the  President,  Dr.  George  E. 
de  Schweinitz. 
The  Chair  announced  that  the  Chairman  of  the  Section  on  Oph- 


Minutes  of  the  Proceedings  697 

thalmology  of  the  American  Medical  Association  wished  to  extend  to 
the  foreign  guests  an  invitation  to  attend  that  meeting  in  St.  Louis, 
May  24  to  26,  inclusive.  A  similar  invitation  was  extended  by  the 
President  of  the  American  Ophthalmological  Society  to  attend  the 
meeting  of  the  Society  in  Washington,  D.  C.,  May  2-4  inclusive. 

Drs.  F.  H.  Verhoeff  and  A.  N.  Lemoine,  of  Boston,  read  a  paper  on 
"  Endophthalmitis  Phacoanaphylactica." 

The  paper  of  Drs.  Verhoeff  and  Lemoine  was  discussed  by  Drs.  Lucien 
Howe,  G.  F.  Rochat,  James  M.  Patton,  L.  C.  Rood,  Arnold  Knapp,  George  S. 
Derby,  Albert  N.  Lemoine,  and  F.  H.  Verhoeff. 

Prof.  Emile  Gallemaerts,  of  Brussels,  Belgium,  at  the  request  of  the  Presi- 
dent, took  the  Chair. 

PROF.  GALLEMAERTS:  The  next  paper  is  by  Dr.  A.  E.  Davis,  of  New  York 
City,  on  "Serum  and  Vaccine  Treatment  for  the  Prevention  and  Cure  of 
Cataract." 

The  paper  of  Dr.  Davis  was  discussed  by  Drs.  Lucien  Howe,  M.  F.  Guyer, 
Henry  H.  Tyson,  F.  A.  Davis,  and  A.  E.  Davis. 

PROF.  G.  F.  ROCHAT,  Gronigen,  Holland,  at  the  request  of  the  President, 
took  the  Chair,  and  announced  that  the  papers  of  Prof.  Barraquer  and  Prof. 
Gallemaerts  would  be  discussed  together.  Prof.  Barraquer's  paper  is  entitled 
"Facoerisis"  ("Phacoerisis"),  and  Prof.  Gallemaerts'  paper  is  on  "Operation 
de  Barraquer"  ("Operation  of  Barraquer"). 

The  papers  of  Professors  Barraquer  and  Gallemaerts  were  discussed  by 
Drs.  Lucien  Howe,  John  Westley  Wright,  John  0.  McReynolds,  L.  D.  Green, 
Col.  R.  H.  Elliot,  Prof.  F.  de  Lapersonne,  Drs.  Lloyd  Mills,  Joseph  A.  White, 
J.  Gray  Clegg,  S.  Gemblath,  Francisco  Poyales,  W.  A.  Fisher,  and  Professors 
Barraquer  and  Gallemaerts. 

PROF.  G.  F.  ROCHAT:  The  paper  of  Dr.  D.  Kostitch,  Belgrade,  Serbia, 
entitled  "Troubles  Oculaires  Consecutifs  a  l'Obs6rvation  Directe  de  PEclipse 
Solaire"  ("Ocular  Troubles  Following  Direct  Observation  of  the  Solar 
Eclipse"),  will  be  read  by  the  Secretary. 

The  paper  of  Dr.  D.  Kostitch  was  discussed  by  Col.  R.  H.  Elliot,  Drs. 
George  MacKay,  J.  Gray  Clegg,  and  Francisco  M.  Fernandez. 

PROF.  G.  F.  ROCHAT:  The  next  paper  on  "Orbital  Marsupialization  and 
Superiority  of  Organic  Grafts  of  Dead  Tissue  in  Establishing  a  Mobile 
Stump,"  will  be  read  by  Dr.  A.  Magitot,  of  Paris. 

The  paper  of  Dr.  Magitot  was  discussed  by  Drs.  J.  N.  Roy  and  A.  Magitot. 

DR.  EDWARD  JACKSON,  Denver,  Col.,  at  the  request  of  the  President, 
took  the  Chair. 

DR.  EDWARD  JACKSON  announced  the  next  paper  by  Dr.  A.  F.  Alonso, 
of  Mexico,  entitled  "La  Peritomia  en  las  Ulceras  Cr6nicas  Vasculares  de  la 
Cornea"  ("Chronic  Vascular  Ulcers  of  the  Cornea"). 

The  paper  of  Dr.  Alonso  was  discussed  by  Drs.  L.  Webster  Fox,  S.  Lewis 
Ziegler,  and  A.  F.  Alonso. 


698  Minutes  of  the  Proceedings 

DR.  EDWARD  JACKSON:  The  last  paper  on  the  program  is  by  Dr.  R.  C. 
Cheney,  of  Boston,  on  "Types  of  Pneumococcus  Found  in  Corneal  Ulcers." 

The  paper  of  Dr.  Cheney  was  discussed  by  Drs.  George  S.  Derby  and 
R.  C.  Cheney. 


'.     THURSDAY  EVENING,  APRIL  27,  1922 

The  Congress  met  in  Colonial  Hall,  and  the  following  addresses 
were  delivered: 

PROF.  LEONARD  T.  TROLAND  (Harvard  University):    "The  Facts  and 
Theories  of  Color  Vision." 

PROF.  M.  G.  GUYER  (University  of  Wisconsin):    "The  Production  and 
Transmission  of  Certain  Eye  Defects." 


FRIDAY  MORNING,  APRIL  28,  1922 

The  session  was  called  to  order  by  the  President,  Dr.  George  E. 
de  Schweinitz. 

COL.  R.  H.  ELLIOT,  London,  England,  read  a  paper  on  "The  Diagnosis 
of  Glaucoma." 

The  paper  of  Col.  Elliot  was  discussed  by  Drs.  John  E.  Weeks,  Luther  C. 
Peter,  Mr.  E.  Treacher  Collins,  Drs.  E.  E.  Blaauw,  J.  W.  Nordenson,  J.  Gray 
Clegg,  George  F.  Keiper,  Arnold  Knapp,  Col.  R.  H.  Elliot,  and  Dr.  George 
W.  Jean. 

Prof.  C.  Charlin,  Santiago,  Chile,  was  not  present  to  read  his  paper, 
"L'fitat  Vasculaire  des  Glaucomateux "  ("fitude  de  100  Malades  de  Glau- 
come  Primitif")  ("Vascular  Condition  of  Glaucomatous  Patients"). 

MR.  E.  TREACHER  COLLINS  took  the  Chair  at  the  request  of  the  Presi 
dent,  and  announced  that  the  paper,  "  Blood- Pressure  in  the  Vessels  of  the 
Eye,"  by  Drs.  A.  Magitot  and  P.  Bailliart,  of  Paris,  would  be  read  by  Dr. 
Magi  tot. 

MR.  E.  TREACHER  COLLINS:  The  next  paper  is  by  Dr.  J.  M.  Wheeler,  of 
New  York  City,  on  "Plastic  Operations  About  the  Eye." 

The  paper  of  Dr.  Wheeler  was  discussed  by  Drs.  W.  E.  Lambert,  John  E. 
Weeks,  and  John  M.  Wheeler. 

MR.  E.  TREACHER  COLLINS:  Prof.  J.  N.  Roy,  of  Montreal,  Canada,  will 
read  his  paper  on  "  Lagophtalmie  Bilate'rale  Consecutive  a  la  Perte  Acci- 
dentelle  de  la  Peau  du  Front,  et  du  Cuir  Chevelu.  Btepharoplastie "  ("Bilat- 
eral Lagophthalmos  Following  Accidental  Loss  of  the  Scalp.  Blepharo- 
plasty"). 

THE  PRESIDENT,  DR.  DE  SCHWEINITZ,  in  the  Chair.  The  next  paper,  by  Mr. 
A.  S.  Percival,  of  Newcastle-on-Tyne,  entitled  "Light  Sense:  The  Practical 


Minutes  of  the  Proceedings  699 

Significance  of  Its  Variations:  Simple  Tests  for  Determining  Them,"  will  be 
read  by  Dr.  Alexander  Duane,  of  New  York  City,  in  the  absence  of  Mr. 
Percival. 

The  paper  of  Mr.  Percival  was  discussed  by  Drs.  C.  E.  Ferree,  Otto 
Roelofs,  Col.  R.  H.  Elliot,  and  Dr.  Alexander  Duane. 

PROF.  C.  E.  FINLAY,  Havana,  Cuba,  took  the  Chair  at  the  request  of  the 
President,  and  announced  the  next  paper  by  Drs.  C.  E.  Ferree  and  G.  Rand, 
of  Bryn  Mawr,  Pa.,  "Some  Contributions  to  the  Science  and  Practice  of 
Ophthalmology." 

The  paper  of  Drs.  Ferree  and  Rand  was  discussed  by  Drs.  Alexander 
Duane,  Luther  C.  Peter,  William  L.  Benedict,  William  Zentmayer,  J.  Gray 
Clegg,  and  C.  E.  Ferree. 

PROF.  C.  E.  FINLAY:  As  Dr.  E.  Junes,  of  Sfax,  Tunis,  is  not  present,  the 
next  paper  is  on  "Carcinoma  of  the  Choroid,"  by  Dr.  Allen  Greenwood,  of 
Boston.  The  paper  of  Dr.  A.  J.  Bedell,  of  Albany,  N.  Y.,  on  "Chloroma," 
will  follow,  and  these  papers  will  be  discussed  together. 

The  papers  of  Drs.  Greenwood  and  Bedell  were  discussed  by  Dr.  George  E. 
de  Schweinitz. 


FRIDAY  AFTERNOON,  APRIL  28,  1922 

BUSINESS  SESSION 

The  meeting  was  held  at  the  building  of  the  Medical  Society  of  the 
District  of  Columbia. 

THE  PRESIDENT:  The  first  order  of  business  is  a  resolution  which  Dr. 
Lucien  Howe  wishes  to  present: 

WHEREAS,  Arrangements  for  any  International  Congress  necessitate  much  time 
and  careful  attention;  and, 

WHEREAS,  The  destruction  by  fire  of  the  hall  and  part  of  the  hotel  agreed  upon 
for  the  meeting  involved  many  and  important  changes,  just  as  the  Congress 
began;  and, 

WHEREAS,  That  emergency  was  met  so  promptly  and  efficiently  by  the  local 
committee  as  not  to  disturb  our  delightful  sojourn  in  Washington;  therefore  be  it 

Resolved,  That  we  express  our  hearty  thanks  to  the  chairman  and  members  of 
the  Committee  on  Arrangements  for  making  these  meetings,  from  first  to  last,  so 
eminently  satisfactory,  and, 

Resolved,  That  our  thanks  be  extended  also  to  each  of  the  chairmen  and  mem- 
bers of  the  various  committees  whose  united  efforts  have  proved  so  efficient  in 
causing  this  to  be  long  remembered  as  the  largest  and  one  of  the  best  organized  of 
any  International  Congress  of  Ophthalmology. 

MR.  E.  TREACHER  COLLINS  (London,  England):  On  behalf  of  my  col- 
leagues, the  British  representatives  to  this  meeting,  I  wish  to  express  our  most 
emphatic  appreciation  of  this  resolution  and  to  cordially  support  it.  We  are 
very  grateful  to  the  officers  for  the  care  and  attention  which  they  have  given 


700  Minutes  of  the  Proceedings 

to  the  carrying  out  of  this  meeting,  and  we  wish  to  express  our  special  indebt- 
edness to  them. 

The  motion  was  unanimously  carried. 

The  Secretary  was  directed  to  spread  the  resolution  upon  the  minutes  of 
the  Congress,  and  to  send  a  copy  to  the  chairman  of  each  special  committee. 

MR.  E.  TREACHER  COLLINS:  I  wish  to  read  a  letter  from  the  President  of 
the  Ophthalmological  Society  of  the  United  Kingdom,  Mr.  J.  Herbert 
Fisher. 

11  Chandos  Street 
Cavendish  Square,  W.  1. 

17th  March,  1922 
Dear  Mr.  Collins: 
International  Congress  of  Ophthalmology. 

The  Council  of  this  Society  strongly  approves  of  the  proposed  suggestion  to 
hold  the  next  International  Congress  in  London  in  1925. 

It  has  been  in  communication  with  the  following  ophthalmic  bodies,  which 
have  all  given  their  approval  and  promised  their  assistance  toward  ensuring  success 
to  such  a  meeting,  namely: 

Ophthalmic  Section,  Royal  Society  of  Medicine. 
Oxford  Ophthalmological  Congress. 
Midland  Ophthalmological  Society. 
North  of  England  Ophthalmological  Society. 
Irish  Ophthalmological  Society. 
Scottish  Ophthalmological  Club. 

Such  a  consensus  of  opinion  may  be  taken  to  represent  the  views  of  British 
ophthalmic  surgeons,  and  the  Council  of  this  Society  has  instructed  me  to  ask 
you  to  convey  an  invitation  (enclosed  herewith)  to  the  International  Congress  of 
Ophthalmology  at  Washington. 

A  similar  congress  has  not  been  held  in  Great  Britain  for  many  years,  and,  if 
the  proposal  is  agreed  to,  it  would  be  esteemed  a  high  honour  to  British  ophthal- 
mology. 

Yours  sincerely, 

(Signed)     J.  HERBERT  FISHER, 

President. 


I  will  hand  to  the  President  a  letter  addressed  to  him. 
THE  .PRESIDENT:  This  letter  reads  as  follows: 

11  Chandos  Street, 
Cavendish  Square,  W.  1. 

17th  March,  1922 
Dr.  G.  E.  de  Schweinitz, 
Chairman  of  the  General  Committee, 
International  Congress  of  Ophthalmology, 
Washington. 
Dear  Sir: 

Ophthalmologists  in  this  country  are  very  desirous  that  the  next  International 
Congress  should  be  held  in  Great  Britain  in  1925;  and  we  shall  esteem  it  a  high 
honour  if  the  Congress  at  Washington  will  accept  this  invitation,  which  our  col- 
league, Mr.  E.  Treacher  Collins,  has  been  asked  to  convey. 


Minutes  of  the  Proceedings  701 

This  proposal  has  met  with  unanimous  approval  not  only  by  the  Council  of 
this  Society,  but  also  by  the  Councils  of  the  following: 

(1)  Ophthalmic  Section,  Royal  Society  of  Medicine,  London. 

(2)  Oxford  Ophthalmological  Congress. 

(3)  Midland  Ophthalmological  Society. 

(4)  North  of  England  Ophthalmological  Society. 

(5)  Irish  Ophthalmological  Society. 

(6)  Scottish  Ophthalmological  Club. 

We  beg  to  remain,  dear  Sir, 

Yours  obediently, 

(Signed)     J.  HERBERT  FISHER, 

President. 

J.  F.  CUNNINGHAM, 
FRANK  JULER, 

Secretaries. 

PROF.  EMILE  GALLEMAERTS  (Brussels,  Belgium):  The  Ophthalmological 
Society  of  Belgium  asked  me  to  bring  before  you  the  same  invitation  as  that 
of  Mr.  E.  Treacher  Collins,  but  in  the  face  of  so  great  an  invitation  from  Mr. 
Collins  I  can  only  present  the  hope  that  in  the  course  of  time  such  invitation 
will  be  received  with  the  applause  accorded  the  invitation  of  Mr.  Collins. 

THE  PRESIDENT:  The  Chair  feels  sure  the  time  will  never  come  when  an 
invitation  from  Belgium  will  not  be  warmly  applauded.  The  Chair  permits 
himself  to  suggest  that,  before  proceeding  with  this  matter,  someone  shall 
move  a  vote  of  thanks  to  Professor  Gallemaerts,  which  he  in  turn  may  convey 
to  his  colleagues  in  Belgium. 

The  motion  was  made  by  Prof.  Allvar  Gullstrand,  seconded,  and  unani- 
mously carried. 

PROF.  ALLVAR  GULLSTRAND  (Upsala,  Sweden):  We  have  received  an 
invitation  from  our  colleagues  of  England,  and  I  should  like  to  point  out  a  few 
hints  at  this  opportunity.  I  am  the  official  delegate  of  the  Government  of  a 
country  that  was  strictly  neutral  during  the  War,  and  I  can  prove  that  I 
was  strictly  neutral,  for  I  have  received,  during  the  War,  honorary  member- 
ships from  both  sides — one  from  Great  Britain  and  one  from  Austria,  and  that 
would  not  have  happened  if  I  had  not  been  neutral.  Now  we  neutrals  stand 
at  a  corner — on  the  one  side  we  see  Germany,  who  thinks  you  are  boycotting 
her  science  and  her  language;  and  on  the  other  side  we  see  yourselves,  and  we 
know  you  are  not. 

I  move  in  the  first  place  that  this  Congress  shall  accept  the  kind  invitation 
that  we  have  received  from  the  Ophthalmological  Society  of  the  United  King- 
dom; and  in  the  second  place  that  this  Congress  shall  express  its  wish  that 
the  next  Congress  is  to  be  strictly  international,  and  that  the  German  lan- 
guage shall  be  an  official  language  among  others. 

DR.  LUCIEN  HOWE  (Buffalo,  N.  Y.) :  In  rising  to  second  this  motion  made 
by  Professor  Gullstrand  I  desire  to  do  so  in  words  which  will  tend  to  clear  up 
an  evident  misunderstanding  concerning  the  languages  to  be  used  at  this 
Congress.  We  all  know  that  when  the  first  steps  were  taken  toward  its  or- 
ganization, over  two  years  ago,  an  invitation  was  transmitted  through  the 


702  Minutes  of  the  Proceedings 

Department  of  State  to  each  of  the  countries  with  which  we  were  then  in 
diplomatic  relations,  requesting  that  a  representative  be  assigned  to  the  Con- 
gress, and  therefore  such  an  invitation  could  not  go  to  those  countries  with 
which  such  diplomatic  relations  did  not  exist  at  that  time. 

This  probably  led  to  the  impression,  unfortunately  widespread  and  often 
repeated,  that  we  Americans  had  "boycotted"'  the  German  language.  The 
fallacy  of  this,  however,  was  shown  by  the  fact  that  in  one  of  the  earliest 
circulars  issued  by  our  Central  Committee  it  was  distinctly  stated  that  any 
language  could  be  used  which  the  speaker  preferred,  provided  it  be  translated 
into  one  of  the  three  official  languages  of  the  Congress. 

Also,  it  seemed  probable  then  that  very  few  colleagues  would  come  just 
now  from  Germany  or  Austria,  and  the  printing  of  notices  and  of  transactions 
in  four  languages  would  involve  a  deficit  even  greater  than  the  one  of  several 
thousand  dollars  which  we  are  now  obliged  to  supply  for  the  publication  in 
only  three  languages. 

Therefore  it  seems  proper  for  some  one  to  prove  that  this  is  an  Inter- 
national Congress,  not  only  in  name,  but  that  it  is  catholic  in  its  scope  and 
hospitable  to  ideas,  no  matter  whence  they  come.  In  other  words,  the  German 
language  should  purposely  be  used  by  some  one  who  was  born  and  bred  in 
America  and  without  a  trace  of  German  predilection.  We  need  that  as  a 
proof  of  consistency.  Speaking  in  German,  Dr.  Howe  continued: 

Deshalb,  Herr  President,  mochte  ich  meiner  Meinung  dahin  Ausdruck 
geben,  dass  solange  wir  gewillt  sind  die  Arbeiten  der  Forscher  anzuerkennen, 
und  unsere  Kenntnisse  dadurch  zu  bereichern,  so  miissten  wir  doch  deutlich 
zeigen  dass  wir  nicht  ihre  Sprache  verbannen.  Es  ist  zwar  moglich,  dass  diese 
Konsequenz,  auf  die  ich  hinweise,  von  den  Anwesenden  missverstanden 
werden,  ebenso  wie  wir  seinerzeit  von  den  Deutschen  misverstanden  wurden, 
ich  bin  aber  bereit  irgend  welchen  Beschuldigungen  entgegen  zu  treten.  Ich 
behaare  also  auf  das  Recht,  wenn  ich  es  wunsche,  die  deutsche,  oder  irgend 
eine  andere  fremde  Sprache  zu  gebrauchen. 

Indem  ich  meine  Zustimmung  fur  die  Annahme  der  Einladung  nach  Lon- 
don abgebe,  hoffe  ich,  gemeinsam  mit  Prof.  Gullstrand  und  will  es  auch  ev. 
fur  die  meisten  der  englischen  Kollegen  hoffen,  dass  beim  nachsten  interjia- 
tionalen  Ophthalmologen  Kongress  Deutsch  als  eine  der  offiziellen  Sprachen 
gelten  wird. 

DR.  GEORGE  MACKAY  (Edinburgh,  Scotland):  I  rise  to  support  the  pro- 
position put  before  you  by  Mr.  E.  Treacher  Collins,  speaking  in  behalf  of  all 
the  ophthalmologic  colleagues  in  Great  Britain,  and  I  trust  I  may  say  of 
Ireland,  inviting  you  most  cordially  to  accept  this  invitation  to  make  your 
next  meeting  place  the  capital  of  the  British  Empire.  The  last  name  in  the 
list  read  is  that  of  the  Scottish  Ophthalmological  Club.  It  is  a  small  body,  but 
I  venture  to  say  it  is  a  very  select  body.  It  represents  a  country  which  has 
ever  stood  for  liberty,  for  progress,  for  freedom.  I  take  it,  gentlemen,  that 
that  is  a  sentiment,  an  aspiration,  which  appeals  to  you  all.  I  beg,  then,  to 
assure  you  that  in  visiting  the  British  Isles  you  come  not  only  to  receive  a 
hearty  welcome  from  London  and  from  England,  but  from  bonnie  Scotland, 
to  which  you  will  find  time  to  extend  your  visit. 


Minutes  of  the  Proceedings  703 

DR.  JOHN  ROWAN  (Glasgow,  Scotland) :  I  wish  to  second  Mr.  E.  Treacher 
Collins'  invitation,  which  I  hope  the  Congress  will  accept,  and  which  I  wish  to 
back  up  from  the  point  of  view  of  the  Scotch  colleagues.  We  hope  that  while 
you  are  there,  either  going  or  coming,  you  will  take  the  northern  route. 
There  are  plenty  of  trains,  three  or  four  lines,  and  it  is  only  about  an  eight-hour 
trip.  We  assure  you  the  clinics  will  be  open  to  you  and  we  will  do  our  best  to 
show  you  all  our  different  methods.  I  am  afraid,  however,  by  the  time  you 
have  attended  the  meetings  in  London  the  wives  and  daughters  will  have 
taken  command  and  that  you  will  be  taken  to  the  north  of  Scotland  for  sight- 
seeing. We  will  do  our  best  in  that  way,  too.  If  you  will  let  us  know  what 
you  want,  we  will  be  pleased  to  do  it.  We  will  try  to  live  up  to  the  standards 
that  have  been  set  at  this  Congress,  although  that  will  be  difficult.  The  work 
has  been  extremely  good,  the  organization  has  been  good,  and  the  discipline 
has  been  good.  There  has  been  no  time  wasted. 

MR.  J.  GRAY  CLEGG  (Manchester,  England) :  There  is  no  delicate  question 
in  the  north  of  England  as  regards  nationality,  and  as  representing  my  col- 
leagues of  the  North  of  England  Ophthalmological  Society  I  wish  to  add  our 
strong  invitation  and  to  express  the  hope  that  this  Congress  will  accept  it. 
The  stimulus  of  this  visit  to  America  will  certainly  set  the  north  of  England 
ball  rolling  at  a  great  pace,  and  I  expect  we  will  be  able  to  have  something  to 
show  you  in  spite  of  the  fact  that  perhaps  we  have  not  been  quite  up  to  the 
mark  in  times  gone  by.  I  have  pleasure,  therefore,  in  expressing  the  hope  of 
the  North  of  England  Ophthalmological  Society  that  you  will  accept  the 
invitation. 

COL.  R.  H.  ELLIOT  (London,  England) :  Nothing  has  been  said  about  Wales 
and  very  little  about  Ireland,  but  I  am  both  Welsh  and  Irish  and  I  am  sure 
both  will  be  as  glad  to  see  you  come  as  any  of  us. 

THE  PRESIDENT:  The  invitation  conveyed  by  Mr.  E.  Treacher  Collins, 
which  bears  the  endorsement  of  the  various  societies  enumerated,  is  now  be- 
fore you.  Does  the  Congress  understand  that  it  includes  the  wish  expressed 
in  Professor  Gullstrand's  motion? 

An  affirmative  answer  having  been  recorded,  the  Congress  by  vote  accepted 
the  invitation  to  hold  the  next  meeting  in  England  in  1925. 

THE  PRESIDENT:  Mr.  Collins,  will  you  please  convey  to  your  confreres 
and  the  societies  enumerated  the  acceptance  by  this  Congress  of  Great 
Britain's  invitation?  Is  there  any  other  business  before  the  Congress? 

DR.  C.  D.  WESCOTT  (Chicago) :  As  a  member  of  the  Hospitality  Committee 
of  Chicago  I  wish  to  extend  an  invitation  to  all  our  guests  and  to  any  mem- 
bers of  the  Congress  to  come  to  Chicago.  We  will  be  glad  to  do  anything  we 
can  to  assist  you  in  seeing  anything  we  have  to  show  you. 

SCIENTIFIC  SESSION 

THE  PRESIDENT:  The  first  number  in  our  scientific  program  this  afternoon 
is  a  paper  on  "Metastatic  Thyroid  Tumor  in  the  Orbit,"  by  Dr.  Arnold 
Knapp,  of  New  York  City. 


704  Minutes  of  the  Proceedings 

The  next  paper  was  by  Mr.  E.  Treacher  Collins,  of  London,  "Hereditary 
Ocular  Degenerations — 'Ophthalmic  Abiotrophies.'  " 

The  paper  of  Mr.  Collins  was  discussed  by  Drs.  C.  E.  Finlay,  F.  H. 
Verhoeff,  George  F.  Libby,  Mary  Buchanan,  William  E.  Bruner,  Mr.  E. 
Treacher  Collins,  Edward  Jackson,  and  E.  E.  Blaauw. 

Drs.  Walter  Scott  Franklin  and  Frederick  C.  Cordes  presented  a  paper 
on  "  Bilateral  Lymphosarcoma  of  the  Orbit  with  Intermittent  Exoph- 
thalmos." 

DR.  A.  TORRES  ESTRADA,  of  Mexico  City,  was  not  present  to  read  his 
paper,  "Mercurials  and  Salvarsan  and  its  Derivatives  in  the  Treatment  of 
Grave  Eczematous  Conjunctivitis  and  Keratitis." 

The  next  paper,  "The  Effects  of  Direct  Instillation  of  Novarsenobillon 
in  the  Conjunctival  Sac  in  Resistant  Cases  of  Congenital  Syphilitic  Inter- 
stitial Keratitis,"  by  Dr.  A.  Renshaw,  of  Manchester,  England,  was  read  by 
Mr.  J.  Gray  Clegg. 

DR.  EDWARD  JACKSON  made  the  following  report: 

The  Committee  appointed  to  report  on  Suggestions  for  Congress  Action  con- 
cluded it  was  quite  impossible  to  give  either  of  the  three  questions  referred  to  it 
any  adequate  consideration  during  the  time  of  this  Congress,  and  recommend 
that  it  be  authorized  to  continue  its  consideration  and  to  report  either  to  a  sub- 
sequent Congress  or  through  the  journals.  After  the  action  taken  today  probably 
the  report  should  be  made  when  the  Congress  meets  in  London.  That  is  the  only 
report  the  committee  has  to  make. 

The  final  paper  on  the  scientific  program  was  "Treatment  of  Infectious 
Keratitis  by  Vaccine,"  by  Dr.  Rovirosa  Virgili,  of  Madrid,  Spain.  Dr. 
Virgili  was  not  present  to.  read  the  paper. 

DR.  ALLEN  GREENWOOD  (Boston) :  I  wish  to  move  a  rising  vote  of  thanks 
to  the  President  for  the  very  able  manner  in  which  he  has  conducted  the 
sessions  of  this  Congress.  And  I  would  like  to  give  the  same  vote  of  thanks 
to  our  Secretary. 

The  motion  seconded  by  Mr.  J.  Gray  Clegg,  and  unanimously  carried. 

THE  PRESIDENT:  Ladies  and  Gentlemen  of  the  Congress :  This  concludes 
the  scientific  program.  I  beg  on  behalf  of  my  colleagues  to  express  our 
best  thanks  for  your  courtesy  and  your  kindness  and  to  reiterate  our  high 
appreciation  of  your  sympathetic  interest  and  your  notable  scientific  con- 
tributions which  have  brought  success  to  the  Congress  of  Ophthalmology. 

ADJOURNMENT. 


ORGANIZATION  OF  THE  CONGRESS 

In  1919,  the  American  Ophthalmological  Society,  the  Section  on 
Ophthalmology  of  the  American  Medical  Association,  and  the 
American  Academy  of  Ophthalmology  and  Oto-Laryngology  each  ap- 
pointed a  committee  of  three  members,  with  instructions  to  formu- 
late plans  for  the  organization  of  an  International  Congress  of  Oph- 
thalmology to  meet  in  the  United  States.  The  membership  of  these 
committees  was  as  follows: 

American  Ophthalmological  Society,  Drs.  G.  E.  de  Schweinitz, 
W.  H.  Wilmer,  and  Frederick  T.  Tooke. 

Section  on  Ophthalmology  of  the  American  Medical  Association, 
Drs.  W.  H.  Wilder,  Lucien  Howe,  and  Francisco  Fernandez. 

American  Academy  of  Ophthalmology  and  Oto-Laryngology,  Drs. 
Edward  Jackson,  W.  B.  Lancaster,  and  Luther  C.  Peter. 

At  a  meeting  in  New  York,  on  October  21,  1919,  an  organization  of 
the  combined  committees  was  effected  with  the  election  of  the  follow- 
ing: Dr.  G.  E.  de  Schweinitz,  Chairman;  Dr.  Edward  Jackson,  Vice- 
Chairman,  and  Dr.  Luther  C.  Peter,  Secretary.  A  temporary  Sub- 
committee on  Time  and  Place  was  appointed,  which  at  a  subsequent 
meeting  recommended  that  the  place  of  meeting  should  be  Washing- 
ton, D.  C.,  April  18,  1922.*  This  recommendation  was  adopted  at  a 
later  meeting  of  the  general  committees  of  the  Congress.  Numerous 
other  sub-committees  were  appointed  by  the  Chairman,  selected  to 
represent  all  sections  of  the  United  States,  as  well  as  Canada,  Cuba, 
Mexico,  and  Central  and  South  America. 

The  several  committees  in  charge  of  the  organization  of  the 
Congress,  as  finally  appointed,  consisted  of  a  General  Committee,  a 
Committee  on  Organization,  a  Committee  on  Scientific  Business,  a 
Committee  on  Arrangements,  a  Committee  on  Membership  and 
Credentials,  a  Committee  on  Finance,  a  Committee  on  Publication, 
and  a  Committee  on  Entertainment  for  each  of  several  leading  cities 
throughout  the  country. 

*  The  final  date  selected  was  April  25-28,  1922. 
45  705 


706  Organization  of  the  Congress 


INTERNATIONAL  CONGRESS  COMMITTEES 
GENERAL  COMMITTEE 

DR.  GEORGE  E.   DE  SCHWEINITZ,  CHAIRMAN 

DR.  EDWARD  JACKSON.  VICE-CHAIRMAN 
DR.   LUTHER  C.   PETER.  SECRETARY-TREASURER 

DR.  FRANCISCO  M.  FERNANDEZ  DR.  FREDERICK  T.  TOOKE 

DR.  LUCIEN   HOWE  DR.  WILLIAM   H.  WILDER 

DR.  WALTER  B.  LANCASTER  DR.  WILLIAM   H.  WlLMER 


SPECIAL  COMMITTEES 
COMMITTEE  ON  ORGANIZATION 

DR.  EDWARD  C.  ELLETT.  CHAIRMAN 

DR.  HENRY  D.  BRUNS  PROF.  R.  PACHECO  LUNA 

DR.  WM.  GORDON  M.  BYERS  DR.  ARCHIBALD  L.  MACLEISH 

DR.  ENRIQUE  B.  DEMAR1A  DR.  WALTER  R.  PARKER 

DR.  ALEXANDER  DUANE  DR.  DANIEL  M.  VELEZ 

DR.  A.  E.  EWING  DR.  CASEY  WOOD 

DR.  HIRAM  WOODS 

COMMITTEE  ON  SCIENTIFIC  BUSINESS 

DR.  EDWARD  JACKSON,  CHAIRMAN 

DR.  GEORGE  s.  DERBY  DR.  THOMAS  B.  HOLLOWAY 

DR.  ALEXANDER  DUANE  DR.  WALTER  B.  LANCASTER 

DR.  MARCUS  FEINGOLD  DR.  URIBE  TRONCOSO 

COMMITTEE  ON  ARRANGEMENTS 

DR.  WILLIAM   H.  WlLMER.  CHAIRMAN 
JOHN  W.   BURKE  DR.  EDWARD  L.  MORRISON 

MAJ.  G.  R.  CALLENDAR  DR.  STEWART  B.  MUNCASTER 

DR.  WILLIAM  T  .DAVIS  DR.  EDWARD  G.  SEIBERT 

DR.  LOUIS  S.  GREENE  DR.  DANIEL  K.  SHUTE 

DR.  CARL  HENNING  DR.  WILLIAM   M.  SWEET 

DR.  ROBERT  S.  LAMB  DR.  SAMUEL  THEOBALD 

DR.  WALTER  E.  LAMBERT  DR.  CASSIUS  D.  WESCOTT 

DR.  OSCAR  A.  MCK1MMIE  DR.  JOSEPH  A.  WHITE 

COMMITTEE  ON  MEMBERSHIP  AND  CREDENTIALS 

DR.  WALTER  R.  PARKER,  CHAIRMAN 

DR.  JAMES  BORDLEY.  JR.  DR.  WILLIAM  R.  MURRAY 

DR.  ALBERT  E.  BULSON,  JR.  DR.  JAMES  M.  PATTON 

DR.  F.  PHINIZY  CALHOUN  DR.  WILLIAM   H.  ROBERTS 

DR.  A.  E.  EWING  DR.  FREDERICK  T.  TOOKE 

DR.  ALLEN  GREENWOOD  DR.  CLARENCE  A.  VEASEY 

DR.  JOHN  O.  MCREYNOLDS  DR.  JOHN  E.  WEEKS 

DR.  WILLIAM  H.  WILDER 


Organization  of  the  Congress 


707 


COMMITTEE  ON  FINANCE 

DR.  LEE  M.  FRANCIS,  CHAIRMAN 

DR.  WILLIAM  L.  BENEDICT  DR.  EMORY  HILL 

DR.  CONRAD  BERENS,  JR.  DR.  CLARENCE  KING 

DR.  w.  GORDON  M.  BYERS  DR.  JOHN  R.  NEWCOMB 

DR.  EDWARD  H.  GARY  DR.  LUTHER  C.  PETER 

DR.  RALPH  A.  FENTON  DR.  VICTOR  C.  SMITH 

DR.  WILLIAM  C.  F1NNOFF  DR.  WILLIAM  P.  WHERRY 

DR.  HARRY  S.  CRADLE  DR.  HILLIARD  WOOD 

COMMITTEE  ON  PUBLICATION 

DR.  WILLIAM  ZENTMAYER.  CHAIRMAN 

DR.  ARNOLD   KNAPP  DR.  LUTHER  C.  PETER,  EX-OFFICIO 

DR.  WILLIAM   M.  SWEET 


LOCAL  COMMITTEES  ON  ENTERTAINMENT 


ANN  ARBOR,   MICH. 

DR.  WALTER  R.  PARKER,  CHAIRMAN 

ATLANTA,  GA. 

DR.  F.  PHIN1ZY  CALHOUN,  CHAIRMAN 

ATLANTIC  CITY.   N.  J. 

DR.   H.  L.   HARLEY,  CHAIRMAN 

BALTIMORE,   MD. 
DR.  JAMES  BORDLEY,  JR.,  CHAIRMAN 

BOSTON,   MASS. 

DR.  F.   H.  VERHOEFF,  CHAIRMAN 

BUFFALO,  N.  Y. 
DR.  E.  G.  STARR,  CHAIRMAN 

CHICAGO,   ILL. 

DR.  CASSIUS  D.  WESCOTT.  CHAIRMAN 

CINCINNATI,  OHIO 

DR.  ROBERT  SATTLER,  CHAIRMAN 

CLEVELAND,  OHIO 

DR.  WILLIAM  EVANS  BRUNER,  CHAIR- 
MAN 

DENVER,  COLO. 

DR.  MELVILLE  BLACK,  CHAIRMAN 

DETROIT,  MICH. 

DR.      GEORGE       E.      FROTHINGHAM. 
CHAIRMAN 

KANSAS  CITY,  MO. 

DR.  J.  L.   MYERS,  CHAIRMAN 

LOUISVILLE.   KY. 

DR.  ADOLPH  O.  PF1NGST,  CHAIRMAN 


LOS  ANGELES.  CAL. 

DR.  ARCHIBALD  L.  MACLE1SH,  CHAIR- 
MAN 

NEW  ORLEANS,   LA. 

DR.  CHARLES  A.  BAHN,  CHAIRMAN 

NEW  YORK,   N.   Y. 

'      DR.  WALTER  E.   LAMBERT.  CHAIRMAN 

OMAHA,   NEB. 

DR.  HAROLD  GIFFORD,  CHAIRMAN 

PHILADELPHIA,   PA. 

DR.  G.  ORAM   RING,  CHAIRMAN 

PITTSBURGH,   PA. 

PITTSBURGH      OPHTHALMOLOGICAL 

SOCIETY 
DR.  GEORGE  H.  SHUMAN,  SECRETARY 

PORTLAND,  ORE. 

DR.  JOSEPH  L.  MCCOOL,  CHAIRMAN 

RICHMOND,   VA. 

DR.  JOSEPH  A.  WHITE,  CHAIRMAN 

ROCHESTER,    MINN. 

DR.  WILLIAM  L.  BENEDICT,  CHAIRMAN 

SAN   FRANCISCO,  CAL. 

DR.  A.  S.  GREEN.  CHAIRMAN 

SPOKANE,  WASH. 

DR.  CLARENCE  A.  VEASEY.  CHAIRMAN 

ST.   LOUIS,   MO. 

DR.  JOHN  GREEN.  JR.,  CHAIRMAN 

ST.  PAUL  AND  MINNEAPOLIS, 
MINN. 

DR.  FRANK  E.   BURCH.  CHAIRMAN 


708  Organization  of  the  Congress 

The  report  of  the  Committees  on  Organization  as  presented  to  each 
of  the  three  component  societies,  was  as  follows: 

It  has  been  resolved,  if  the  report  of  the  Committees  is  accepted,  to  issue 
invitations  as  speedily  as  possible  to  join  this  Congress  to  physicians  (oph- 
.  thalmologists  and  others  interested  in  ophthalmology)  in  good  standing  in 
the  American  Medical  Association  or  other  recognized  scientific  and  medical 
societies  of  the  United  States  and  Canada,  and  to  physicians  (ophthal- 
mologists) in  good  standing  in  Cuba,  Mexico,  Central  and  South  America,  and 
also  to  physicians  through  their  constituted  ophthalmologic  societies  in  those 
foreign  countries  with  whom  we  are  (March  6,  1920)  in  diplomatic  relation- 
ship. 

It  was  further  resolved  that  the  official  languages  of  the  Congress  shall  be 
English,  French,  and  Spanish,  and  that  the  membership  fee  shall  be  ten  (10) 
dollars  in  United  States  money. 

The  report  of  the  Committee  was  received  and  accepted  by  each  of 
the  three  societies,  and  the  following  invitation  was  transmitted  by 
the  Department  of  State  through  the  various  embassies  and  lega- 
tions abroad: 

The  American  Ophthalmological  Society,  The  Section  on  Ophthalmology 
of  The  American  Medical  Association,  and  The  American  Academy  of  Oph- 
thalmology and  Oto-Laryngology  have  the  honor  to  invite,  through  his 
Excellency,  the  Minister  of  Foreign  Affairs,  the  Government  of  -  — ,  to 
participate  in  An  International  Congress  of  Ophthalmology,  by  sending  an 
official  delegate. 

The  Congress  will  be  held  under  the  auspices  of  these  Societies  in  the  City 
of  Washington,  United  States  of  America,  April  25th  to  April  28th,  1922. 

GENERAL  COMMITTEE 
Dr.  George  E.  de  Schweinitz,  Chairman 

Dr.  Edward  Jackson,  Vice-Chairman 
Dr.  Luther  C.  Peter,  Secretary-Treasurer 

Dr.  William  H.  Wilder  Dr.  William  H.  Wilmer 

Dr.  Lucien  Howe  Dr.  Frederick  T.  Tooke 

Dr.  Francisco  M.  Fernandez  Dr.  Walter  B.  Lancaster 

SPECIAL  COMMITTEES 

Dr.  Edward  C.  Ellett,  Chairman  of  Committee  on  Organization 

Dr.  Walter  R.  Parker,  Chairman  of  Committee  on  Membership  and  Credentials 

Dr.  William  H.  Wilmer,  Chairman  of  Committee  on  Arrangements 

Dr.  Edward  Jackson,  Chairman  of  Committee  on  Scientific  Program 

Dr.  Lee  M.  Francis,  Chairman  of  Committee  on  Finance 

Office  of  the  Secretary,  1529  Spruce  Street, 

Philadelphia,  Pennsylvania,  U.  S.  A. 
June  the  first,  nineteen  hundred  and  twenty-one 


Organization  of  the  Congress  709 

This  invitation  was  sent  to  the  following  countries: 

Argentina,  Belgium,  Bolivia,  Brazil,  Bulgaria,  Chile,  China,  Colombia, 
Costa  Rica,  Cuba,  Czecho-Slovakia,  Denmark,  Ecuador,  Finland,  France, 
England,  Egypt,  Greece,  Guatamala,  Honduras,  Italy,  Japan,  Morocco, 
Netherlands,  Nicaragua,  Norway,  Panama,  Paraguay,  Persia,  Peru,  Poland, 
Portugal,  Roumania,  Salvador,  Kingdom  of  Serbs,  Croats  and  Slovenes,  Siam, 
Spain,  Sweden,  Switzerland,  Turkey,  Uraguay,  Venezuela. 

The  Committee  on  Membership  sent  invitations  to  the  leading 
members  of  the  profession  interested  in  ophthalmology  and  to  the 
various  ophthalmological  societies  in  these  countries,  and  in  Canada, 
Mexico,  and  the  United  States,  asking  that  they  make  application  for 
membership  in  the  Congress.  The  members  of  the  Congress  and  the 
societies  represented  are  printed  in  the  volume. 


INDEX 


ADDRESS  of  Welcome,  31 
Alonso,  Antonio  F.,  371,  378 
Andrade,  Cesario,  56 
Anomalies  of  Ocular  Development  and 
Pigmentation,  528 

Bailliart,  P.,  435 

Balbuena,  Felix  Fernandez,   690,  696 

Barraquer,  Ignacio,  67,  230,  313,  338, 

695 

Barraquer,  Operation  de,  319 
Bedell,  Arthur  J.,  588 
Benedict,  Wm.  L., 
Beraun,  Aurelio,  5,  6,  93 
Blaauw,  E.  E.,  49,  80,  140,  431,  532 
Blindness,  Hereditary,  in  Rabbits,  696 
Blood-pressure  in  the  Vessels  of  the  Eve, 

435 

Books,  Historic,  696 
Brown,  E.  V.  L.,  696 
Bruner,  Wm.  E.,  141 
Buchanan,  Mary,  141 
Byers,  W.  Gordon  M.,  696 

Cajal  Method,  New  Technic,  696 

Callender,  G.  R.,  695 

Campimeter,  Rotating,  695 

Campodonico,  E.,  201 

Carvil,  Maud,  154 

Castresana,  B.,  171 

Cataract,  Coralliform,  Protein  Crystals, 

696 

Moving  Pictures  Showing  In- 

tracapsular  Operation,  695 

Serum  and  Vaccine  Treatment 

for  the  Prevention  and  Cure 

of,  284 

Chalazia,  Protozoan  Bodies  in,  696 
Charlin,  Carlos,  383 
Cheney,  Robert  Cartwright,  378,  382 
Chirurgie  oculaire,  Des  Enseignements 

de  la  Guerre  en,  39 
Chloroma,  588 
Choroid,  Carcinoma  of,  567 
Clegg,  J.  Gray,  170,  229,  337,359,432, 

517,  528,  532,  696,  703 
Collins,  E.  Treacher,  5,  6,  68,  103,  142, 

231,  430,  532,  695,  699,  700 
Color-blindness,    Improved   Test,    696 
Color  Vision,  The  Facts  and  Theories 
of,  652 


Committee  Report  on  Suggestion  for 

Congress  Action,  704 
Committees  of  An  International  Con- 
gress, 706 
Organization,  706 
Organization  of  An  Inter- 
national Congress,  705 
Resolution  of  Thanks  to 

Various,  699 

Congress,  International,       Invitation, 
from   British  Ophthalmo- 
logical  Societies,  699 
Members  of,  7 
Minutes  of  Proceedings,  692 
Officers  of,  5 
Organization  of,  705 
Contents,  3 

Coolidge.  Hon.  Calvin  D.,  31 
Cordes,  Fred  C.,  579 
Corneal  Ulcers,  Types  of  Pneumococcus 

Found  in,  378 

Credentials,  Presentation,  32 
Crisp,  W.  H.,  696 

Davis,  A.  Edward,  284,  312 
Davis,  Frederick  A.,  311 
Del  Monte,  Alberts,  696 
Derby,  George  S.,  48,  282,  382 
Development  of  Human  Eye,  696 
Diaphragm  Lamps  in  Ophthalmology,  69 
Dominici,  Santos,  5 
Duane,  Alexander,  476,  514 

Echanges  d'Eau  et  d'lons  a  Travers  la 

^Cqrnee,  Les,  157 
1'Eclipse    Solaire,    Troubles    Oculaires 

Consecutifs  a  1'Observation  Directe 

de,  340 
Elliot,  R.  H.,  66,  93,  333,  356,  405,  434, 

476,  695,  703 
Endophthalmitis    Phacoanaphylactica, 

234 
Estrabismo,  Nuevo  Tratamiento  Qui- 

rurgico,  171 

Estrada,  Antonio  Torres,  533,  704 
Ewing,  A.  E.,  604 
Exhibit  for   Museum,   A.   A.   O.   and 

O.  L.,  696 

Eye  Defects,  The  Production  and  Trans- 
mission of  Certain,  669 
Transmitted,  696 


711 


712 


Index 


Facoeresis,  313 

Feingold,  M.,  63 

Fernandez,  Francisco  M.,  5,  6,  93,  359 

Ferree,  C.  E.,  474,  479,  518 

Finlay,  C.  E.,  5,  6,  139,  144,  156 

Finnoff,  William  C.,  229,  696 

Fisher,  W.  A.,  337 

Floria,  Salvatore,  5,  6 

Fox,  L.  Webster,  376 

Franco,  Pimental,  5,  6 

Franklin,  Walter  Scott,  579 

Gallemaerts,  Emile,  5,  6,  319,  339,  701 
Garrison,  F.  H.,  6 
Gemblath,  S.,  95,  102,  337 
Glaucoma,  The  Diagnosis  of,  405 

Elliot  Sign,  695 
Glaucomateux,  L  'Etat  Vasculaire  des, 

383 

Gonzalez,  Jos6  de  Jesus,  81 
Cradle,  Harry  S.,  79 
Green,  Louis  D.,  332 
Greenwood,  Allen,  48,  567,  704 
Gullstrand,  Allvar,  5,  6,  69,  80,  695 
Guyer,  M.  F.,  310,  669,  696,  698 

Harford,  Chas.  F.,  160 

Holloway,  T.  B.,  64 

Hons,  William  Z.,  5 

Hooker,  Jas.  F.,  6 

Howe,  Lucien,  5,  281,  309,  329,  696, 

699,  701 
Hyalitis,  Asteroid,  696 

Jackson,  Edward,  5,  78,  140,  532,  704 
Jean,  Geo.  W.,  433 
Jennings,  J.  Ellis,  696 
Junes,  Emile,  520 

Keratitis,  Congenital  Syphilitic  Inter- 
stitial, The  Effect  of  Direct  Instilla- 
tion of  Novarsenobillon  in  the 
Conjunctival  Sac  in  Resistant  Cases, 
548 

Keiper,  George  F.,  169,  433 

Kerry,  Richard,  233 

Knapp,  Arnold,  282,  433,  573 

Kostitch,  Dragoutine,  340 

Krimsky,  Joseph,  102 

Lacrimal  Passageways,  On  the  Clin- 
ical Anatomy  of  the  Efferent,  625 

Lagophtalmie  Bilat£rale  Consecutive  a 
la  Perte  Accidentelle  de  la  Peau  du 
Front,  et  du  Cuir  Chevelu.  B16ph- 
aroplastie,  460 

Lambert,  W.  E.,  459 

Lancaster,  Walter  B.,  153 

Lapersonne,  F.  de,  5,  6,  39,  49,  102,  156, 
335 


Lasalle,  Albert,  5 

Lempine,  A.  N.,  234,  282 

Lewis,  F.  Park,  67 

Li,  T.  M.,  5,  6 

Libby,  Geo.  F.,  140 

Light-Sense :  The  Practical  Significance 

of  its  Variations:     Simple  Tests  for 

Determining  Them,  468 
Lister,  Sir  William,  50 

Mackay,  George,  5,  6,  357,  695,  702 
Magitot,  A.,  359,  369,  435,  696 
Magitot,  A.,  and  Bailliart,  P.,  435 
McCaw,  John  A.,  695 
McMullen,  John,  6,  102 
McReynolds,  John   O.,  212,  331,   377 
Mills,  Lloyd,  94,  335 
Morax,  V.,  157 

Noble,  Robert  E.,  695 

Nomenclature,  Ophthalmologic  versus 

Anatomic,  607 
Nordenson,  J.  W.,  66,  432,  695 

Ocular  Degenerations,  Hereditary, 

"Ophthalmic  Abiotrophies,"  103 
Operations   (Plastic)   About  the  Eve, 

443 

Orbit,  Bilateral  Lymphosarcoma  with 
Intermittent      Exophthalmos, 
579 
Metastatic   Thyroid   Tumor   in 

the,  573 
Some  Descriptive  Errors  in  the 

Anatomy  of,  617 

Orbital  Marsupialization  and  Superior- 
ity of  Organic  Grafts  of  Dead  Tissue 
in  Establishing  a  Mobile  Stump,  359 

Parinaud's  Conjunctivitis,  Lesions  and 

Organisms,  696 
Patton,  Jas.  M.,  281 
Penichet,  Jesus  W.,  5,  6,  101 
Percival,  Archibald  Stanley,  468 
Perimetric  Technic,  Standardization  of, 

615 

Perimetry,  695 
Peritomia    en    las    Ulceras    Cronicas 

Vasculares  de  la  Cornea,  371 
Peter,  Luther  C.,  5,  429,  515,  615,  695 
Photography,  Centric,  of  Fundus,  695 
Poyales,  Dr.  Francisco,  5,  214,  233 
Pregnancy,  Bitemporal  Contraction  of 

Visual  Fields  in,  144 
Prince,  A.  E.,  212 
Proceedings,  Minutes  of,  692 
Propositions  for  Congress  Action,  604 
Psychopathology  in  Ophthalmic  Prac- 
tice, 160 


Index 


713 


Pterygium,  A  New   Procedure  in  the 
Excision  Method  of,  201 
The    Subconjunctival  Ex- 
cision of,  205 

Queratitis  Infecciosas,  Tratamientos, 
por  las  Vacunas,  551 

Rand,  G.,  479 

Refraction,  Le  Diagnostic  et  la  Mesure 
des  Vices,  au  Moyen  de  la  Fente 
St6nopeique  el-  du  Cadran  Horaire, 
520 

Renshaw,  Arnold,  548 

Representatives,  Official  Government,  5 

Retina,  A  New  Technic  for  the  Appli- 
cation of  the  Method  of  Cajal  to  Sec- 
tions of  the,  690 

Rochat,  G.  F.,  5,  6,  49,  80 

Roelofs,  Otto,  475 

Rood,  L.  C.,  281 

Rowan,  John,  703 

Roy,  J.  N.,  368,  460 

Salutatory  of  President,  37 
Schaeffer,  J.  Parsons,  625,  696 
Schweinitz,  G.  E.  de,  5,  37,  572,  704 
Science  and  Practice  of  Ophthalmology, 

Some  Contributions  to,  479 
Scientific  Papers  and  Addresses,  39 
Shrunken  Eye,  Changes  in,  696 
Smtomas  Oculares  del  Envenenamiento 

por  el  Piquete  de  Alacran,  81 
Soriano,  Francisco  J.,  5,  6 
Stark,  H.  H.,  230 


Tooke,  Fred.  T.,  48 

Trachoma,    Traitement    du,    par    les 

Injections    sous    Conjonctivales    de 

Cyanure  de  Mercure,  95 
Tratamiento  de  las  Formas  Graves  de 

Conjuntivitis  y  Queratitis  Eczema- 

tosas,  533 

Trephines,  Clockwork  and  Cable,  695 
Troland,  Leonard  Thompson,  652,  698 
Troncoso,  M.  Uribe,  607 
Tuberculosis,  la  Ocular  Infantile,  214 

Ocular,  696 
Tyson,  Henry  H.,  310 

Uveokeratitis,  Acute  Tuberculous,  696 

Verhoeff,  F.  H.,  68,  139,  232,  234,  283, 

696 

Verhoeff,  F.  H.,  and  Lemoine,  A.  N.,  234 
Virgili,  Rovirosa,  551 
Visual  Tests.  The  Value  of  Letters  and 

Characters  as,  604 
Vitreous,  Detachment  of,  50 

Weeks,  John  E.,  65,  230,  429,  459 

Wescott,  C.  D.,  703 

Wheeler,  John  M.,  443 

White,  Jos.  A.,  336 

Whitnall,  S.  E.,  617,  696 

Wood,  Casey  A.,  696 

Wright,  John  Westley,  330 

Zentmayer,  William,  517 
Ziegler,  S.  Lewis,  205,  213 


UNIVERSITY  OF  CALIFORNIA  LIBRARY 

Los  Angeles 
This  book  is  DUE  on  the  last  date  stamped  below. 


NOV 


Form  L9-107n-3,'48  ( A7920 )  444 


LC 


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